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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 Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. f � r Job Address F b- -� City"2�"t Siz&0-CAJZOJ PM Owner's Name Address 416ex 627 Irl/ Phone Contractor Address 60, -767 License No. ];7° 2-7-(4' Phone V4_5�d' TYPE OF WELL/PUMP: NEW WELL CJ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Grave! Pack ❑ Tracy Type of Casing Specifications F] Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done L7 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth er Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALL ON I )(,!!PAIR ADDITION DESTRUCTION I 1 (No septic system permitted if ublic sewer is `// available within 200 fe Installation will serve: Residence_ Commercial— Other Number of living units: Number of b drooms Character of soil to a depth of 3 feet: k4d�,;- Water tab) d th SEPTIC TANK ❑ Type/Mfg Capacity_ No. Comp rtme s PKG. TREATMENT PLT. ❑ _-r x Method of Disposal Distance to nearest: Well Foundation Property Line I , LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line f !( tF SEEPAGE PITS ,�h Depth Size T�Number SUMPS !❑ Distance to nearest: Well /A'�-Foundation -162'1t 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, arTti-,- kc„ 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 Cal rnia." r �J The applicant st c if all ruir d q pections. Complete drawing-on reverse si Signed X Title: t Date: O ART NT USE ONLY Application Accepted by Date Pit a or Grout Inspection b bate �� Final Inspection b Dat Additional Comments: ❑ Sik 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 INFO AMOUNT DUE AMOUNT REMITTED CK SH RECEIVED BY DATE PERMIT/'/ NO. ♦ EH 13-21(REV. /n 5) 7-27-V /1.. I!3 Ek 11-28 LJ l 1