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c � APPLICATION FOR PERMIT h r SAN JOAQUIN LOCAL HEALTH DISTRICT " `` r '' 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (200) 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 Local Health District. r Job Address gull J ax&M-) ` . j` City X&O Lot Size Q-PA P-4 J PM Owner's Name LLQ. Jm ir]Q(l l Address hone o7 Contractor 11 E Address 25- icense No. Phan, i f TYPE OF WELL/PUMP: V NEW WELL �3i WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 66niE SEWER LINES DISPOSAL FLD. PROP. LINE I FOUNDATION = AGRICULTURE WELL --OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Tom+ ❑ Industrial ElOpen Bottom Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private CK Gravel Pack © Tracy Type of Casing Ryt?, Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal S� T 6i Type of G t Xi Irrigation _--Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 0 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 jDistance to nearest: Well Foundation Property Line t LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line P' SEEPAGE PITS ❑ Depth Sire Number i ` SUMPS O Distance'to nearest: _ Well Foundation Property Line - DISPOSAL PONDS ❑ 1 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. 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 appli ant ust call for all requ' d inspections. Complete drawing on r erre side. Signed X.7 Title: Date: Il7 F MENT E ONLY Application Accepted by A Date '� Area Pit or Grout Inspection by Date Final Inspection by Da Additional Comments. ❑ Stk 466-6781 Lodi 369-3621___ anteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies . Environ rffi5ntal Health Permit/Services 1601 E. Hazekon Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED' C RECEIVED BY DATE PERMIT'N0. + EH 1428(REV.t/e 51 `0 Q f7/ C17