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�. APPLICATION FOR PERMIT ! SAN JOAQUIN LOCAL HEALTH DISTRICT I 1601 E. HAZEL T ON AVE.,;STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r (Complete in Triplicate) �e Application is hereby made to the San Joaquin Local Health District fora t r made H compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of N permit to construct and/or install the work herein described. This application is � Local Health District. - e San Joaquin Job Address k ,.. `� l,Y 'Lot Size PM �-._ . Owner's Nanie � `_ / �� Address �+ Phone Contractor 01 _) TYPE OF WELL/PUMP: t —' �"�"T — — License No. Phone? o NEW WELL ❑ WELL REPLACEMENT ❑ 4 "�"" —0 h.. PUMP INSTALLATION ❑ = bESTRUCTION ❑ _{ SYSTEM REPAIR ❑ `OYHER ❑ DISTANCE TO NEAREST: SEPTIC TANK �� SEWER LINES FOUNDATION! �-f"� k DISPOSAL FLD. PROP. LINE ! G�iICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE r TYPE OF WELL <'PROBLEM AREA CONSTRUCTION SPEClFjCATIONS ❑ Industrial ❑ Open Bottom —I'D Manteca �1++ .h' Dia. of Well Excavation r- € El ❑ Gravel Pack ❑ Trac x Dia, of Well Casing T I Y Type of Casing f5pec)fications 1 1 ❑ Public w.-._„ Dep' ❑ Other Cl Delta Depth of Grout Seal ,.t I ❑ Irrigation err Type of Grout —Approx. Depth ❑ Eastern :Surface S¢al Installed by � � 4 � ! Repair Work Done '❑ Type of Pump ; H.P. "� r State Work Done �l Wel! Destruction, ❑ Well Diameter _'� L Sealing Material (top�50'i ' Depth rFiller-Mate al-1 Below 50'1 - TYPE.OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ~ 4 .� ❑ t. t septic system permitted ikpublic'sewe`r-is�- E Installation will serve: Residence available within 200 feet.) �=� � Commercial Other j Number of living units: Numberofbedrooms Character of soil to a depth of 3 feet: € �SEPJT C TANK ElT e/Mf- ` Yp g Water table depth �.i r� PKG. TREATMENT PLT, CI Capacity No. Compartments ' `ter Method of Disposal 1x Distance to nearest: WellFoundation Property Line-,J0t LEACHING LINE ❑ No. &_LengtI4 of)tries es FILTER 8ED E3Distance to rieart: Well Total length/size If 0 � '1 F undation�_� Property Line - - _ 6 SEEPAGE PITS ❑ Depth " " y SUMPS Size Number 4 ❑ Distance to nearest: Well DISPOSAL PONDS' ❑ / Foundation_7 __ Property Line t 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. � r ! Home owner or licensed agent's signature certifies the Distri in employ an following: :'I certify that in the performance of the work for which this perrfii Is issued, I shall not A Y y person in such manner as to become subject to workman's coin f>ensation.laws of California."Contractor's-hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which ski this permit is issued, f ll employ persons subject tto.workman's compensa-tion laws of California." f 1 The applicant m st'all for all quired i pLions. Complete drawing on feverse side. Signed X `y i Title:. _'7 Date: FOR D A TR MENT USE ONLY # � . / f Application Accepted by /��'v�'' '1 ri fes. Date Area / PI or Grout Inspection % r { / / e D e inal Inspection by -"_Additional-Comment ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca a23-7104 . ❑ Trac 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNTDUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'No. + Eli a3-24 IRE'.i i x 51 U EH 14-26