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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 L(HAZE`i ON AVE., STOCKTON, CA s Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin f Local Health District. / c�5 k f%,��C ,]f' 4 1 Job Address �/2C1 . omCity�/ �hd Lot Size PM 17;C*7 i9s7- �o�VT. MEn A-41 �:` Owner's Name Atl ,C7�lr` 44"ePhone �j� I., C.��M2W Contractor/�!/ iP/�'l�iS/S 5�C5. Address��2-0/.LG'��_�License Na.�Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHFR ❑ l DISTANCE TO NEAREST: SEPTIC TANK <7S-t- SEWER LINES J DISPOSAL FLD. 1:5d>1" PROP. LINE FOUNDATION �� AGRICULTURE WELL ,� -OTHER WELL_----- PITS/SUMPS C ` INTENDED USE TYPE OF WELL^ PRO11LEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Ae: Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout Y r ❑ Irrigation AILT-Approx. Depth ❑ Eastern Surface Seal Installed by CA2T Repair Work Done ❑ Type of Pump H.P. 3..— State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 509 Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is � available within 200 feet.) Installation will serve: Residence_ Commercial— Other -- Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal r Distance to nearest: _Well -WFoundation Property Line LEACHING L'1NE ❑ No&Length of lines 'Total length/size" r \�,%FIL ER BED ❑ Distance to nearest: WellF,ound6tion Property Line k 1 T f-_ �•--. t #`'^ }• SEEPAGE PITS ©Depths ') Size — Number !P SUMPS f Distance•lto"nearest: Well Foundation Property Line DISPOSAL PONDS Elf l i 1 I hereby certify ons that )'have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and g rules-and regulatiof the San Joaquin Local Health District. Homeowner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of Cai'rfornia." Contractor's hiring or sub-contracting signature certifiesithe following:,"I c_ertify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws Bf California.' 1 The applicant ` squire ,,.Complete drawing-oh`•re id - Signed X ate: FOR DEPARTMENT USE ONLY Application Accepted by Date (al�~ Area Pit or Grout Inspection Date Final Inspection by Date Additional Comments: • I ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 _ ¢� -FEE-Y AMOUNT DUE —AMOUNT REMITTED CK RECEIVED BY F � .....,, -- - __ _ INFO r• = CASH r DATE pPERMIT•NO. 1741-1 + EH18-24IREV.1/a 5) Oro EH 14.28 V