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APPLICATION FOR PERMIT SCANNED SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEILTON AVE., STOCKTON, CA Telepholie (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Q I Ok ,p 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 Local Health District. Z! �, ; �z�CUA-�—.�J ._. - . _ � dl7- 210 '. Job Address n/1,4111P d y' C51cs C-" !`W0' ity Lot Size CRO a410'ef PM i9CaAa od 9:��b Owner's Name v«/�' Address � ,h°�" Phone Contractor •L/ Address 4t u 4 License No. Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ �p � e- CSN PUMP INSTALLATION � I SYSTEM REPAIR ❑ OTHER El /OtI tom` DISTANCE TO NEAREST: SEPTIC TANK — /TT) f --SE ERhLI.f�ES DISPOSAL FLD. PROP. LINE s I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom El Manteca Dia. of Well Excavation...��/� Dia. of Well Casing, I Cr(,D Domestic/Private Gravel Pack ❑ Tracy Type of Casing_ U.0 Specifications ('1 Public ❑ Other Ll Delta Depth of Grout Seal �� M'�/ Type of Grout CLQ I�t irrigation ..24*.'Approx. Depth I I Eastern Surface Seal Installed by c�Q�'► _ Repair Work Done ❑ Type of Pump [ H.P. �� State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50'1 - Depth ' Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I 1 DESTRUCTION l I (No septic system permitted if public sewer is - - - ---�- "" AW015ble-within-200 feet.) Installation will serve: Residence— Commercial_ Other Number of living units: Number.of,bedrooms 1 4 Character of soil to a depth of 3 feet: `°V• "� Water table depth e SEPTIC TANK ❑ Type/Mfg . '� 'Capacity -.No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation a Property Line ! LEACHING LINE ❑ No- & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I'] Depth Size _ Number I SUMPS ❑ Distance to.nearest,. Well Foundation Property Line E DISPOSAL PONDS ❑ I I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and' rules and regulations of the San Joaquin Local Health District. j Home owner 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, I✓ employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature:-, certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of.California." S. The applicant must call for all rauired inspections. omplete drawing on reverse side. .,,.Signed-X - Title: Date: DEPARTMENT USE-ONLY Application Accepted by • CA 4< Date ��p+� Area Pit or Grout Inspection by Date1� Final Inspection by Z: 7f 1i* Dat azz Additional Comments: ❑ Stk 466-6781 C) 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' AMOUNT DUE AMOUNT REMITTED CA H RECEIVED BY DATE PERMIT NO. CK t INFO ♦.EHt3-24 1REV.i i x 51 t C) EH 14-26