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- gt)Q , APPLICATION FOR PERMIT � j SAN JOAO.UIN,LOCAL HEALTH DISTRICT 'i 1601 E. HAZETON AVE., STOCKTON, CA S JPO Telephone (209) 466-6781 PERMIT EXPIRES i YEAR FROM DATE ISSUED (Con plete in Triplicate). :.l F 4� `,cation is Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein B�scr�bed. rr��1i made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for welltpump and the Rules and Regulatict Joaquin Local Health District v s f`ovi ✓l A l� F_ �t=4 VIA � City � c��01^/Lot Size � PM Job Address Cly s AddressD0Ift 0 S Tr Phone t f Owner's Name= y -� f �rCm�on7' tH 4`15'3-$ i Contractor t �h Address " f License No. (o S Phoney/s 6 r TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 1-1 ,Sp I L Or. I+ply PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER I 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 j1. Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications r„ h�� Delta i Depth of Grout Seal Type of Grout a �` ❑ Public ! Other eorl _s 0 ❑�irrigation y �4 prox. Depth ❑ Eastern l Surface Seal Installed by CCK -4 Frepairr ork-Do e5�❑ Type of Pump H.P„ State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Fill " Material (Below 501 TYPE OF SEP WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ ( ptic system permitted if public sewer is i` available within 200 feet.} f Installation will se e: Residence Commercial Other 4 Number of living unit " Number of bedrooms ^'- 1� Character of soil to a de of 3 feet: J. Water table depth k SEPTIC TANK ❑ /Mfg Capacity No. Compartments I PKG. TREATMENT PLT. ❑ i Method of Disposal Distance nearest: Well ii Foundation Property Line i LEACHING LINE ❑ No. & Length of It Total length/size FILTER BED ❑ Distance to n est: ell .1 Foundation Property Line SEEPAGE PITS ❑m Dept Size Number SUMPS ❑ - ance to nearest: Well d�, oundation x Property tine r fq 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'District.E 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 i e rformance of the work for which this permit is issued,I shall employ persons subject to workman's compansa + tion laws of C rnia." i� €k The app' nt st call for all required spections. Complete drawing on reverse side. Title:' �/ tx Date: Signed X . t _ FOR DEPARTMENT USE ONLY i Date Area Application Accepted by Pit or Grout Inspection by ' Dat Final Inspection by Date Additional Comments: ❑ 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 4 4 FEE 3 } INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED tiY ATE PER NO. "+ EH.13-24(REV.1/H5) EH 14-28