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�J• P APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA 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 Ord' nce No. or sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin, Local Health District, XJob Address APS o3 —a3 �rlt/P City Lot Size PM Owner's Name Fr� e'�o Address Phone Contractor ![-SLI'Address 1+� �/�6 License No.QPhone TYPE OF WELL/PUMP: NEW WELL D WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER V_ + DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE �F4 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS n� q INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation g ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing �irnis _ f'7 Public ❑ Other Ll Delta Depth of Grout Seal Type "Q"L- I I Irrigation _Approx. Depth t I Eastern Surface Seal Installed by Repair Work Done D Type of Pump H.P. State Work Dane k Well Destruction D Well Diameter Sealing Material (top 50') Depth Filler Material {Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION Cl REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if publicse er is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other � �tO'a C -P fr y�/`� Number of living units: Number of bedrooms (`' Character of soil to a depth of 3 feet: "' Water table depth -40 SEPTIC TANK ❑ Type/Mfg Canacitv N Compartments r__ PKG. TREATMENT PLT. CZ;?, Me od of Disposal Distance to nearest: Well undatio (J ✓ Propert ine / (� LEACHING LINE ❑ No. & Length of lines tal length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS L1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 Di"strict. 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 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." The apphca 41 ired inspections. Complete drawing on r Wdr Signed X Title: Date: Z� USE OfVApplication Accepted by042_h�= Date Area Pit or Grout Inspection by Date Final Inspection by Date 1�- Additional Comments: ❑ Stk 466-6761 ❑ 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 CK 49 FEE INFO AMOUNT DUE AMRUNT REMITTED CASH RECEIVED BY DATE PERMI-r NO. + EH 13-24(REV. /n 5) EH 14-28 FI 4+d r i