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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 I (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for 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. Job Address f City 'Lot Size PM -, wner's Name G 'Y dfh'1�®/. Address __i(J �+� Fes,/ l Phone Contractor A Address r l �/�.� .a.� �icense No. P h a n e TYPE OF WELL/PUMP: NEW WELL,22 WELL REPLACEMENT ❑ DESTRUCTION ❑ 1 PA,UMP INSTALLATION SYSTEM REPAIR❑ OTHER ❑ f * DISTANCE TO NEAREST: 9tPTIC 7AN1< SEWER LINES1!_ DISPOSAL FLD.� PROP. LINE t i FOUNDATION 7A — AGRICULTURE WELL _ OTHER WELL_ = PITS/SUMPS INTENDED U5ETYPE OF WELL PR08LEM K;R A'x iCONSTRUCTlON SPECIFICATIONS ❑ Industrial ❑ Open Bottom- ❑ Manteca Dia. of Well Excavation Dia. of Well Casing )JDomestic/Private k1fravel Pack ❑ Tracy Type of Casing_ , Specifications.11 l nPublic I7 Other 171Delta _Depth of Grout Seal �d® Type of Grout��pl I I Irrigation Approx.;Depth l I Eastern _ Surface Seel Installed by r Repair Work Done ❑ Type.oump 2R3 H.P. �~ ^ State Work Done _ Well Destruction ❑ Well Diameter Sealing Mate alr_itop;50'1' Depth Filler Material lBelow_50'I, ' TYPE OF SEPTIC WORK: . NEW INSTALLATION l l f1EPAIWADDITION] I DESTRUCTION-(_I-(No septic system-permitted if public sewer is I available within 200.,feet.I Installation will serve: Residence_ Commercial_r�.Other �l ,.- T• Number of living units: Number of bedrooms l ("'Character of soil to a depth o0'feet: �� - i� p 4 `-; _ Water table depth NZSEPTIC�TANK ❑ Type/Mfg # ,f- Capacity No. Compartments PKG. TREATMENT PLT- ❑ { Method of Disposal r hI •T ) A r�� Distance to nearest: Well iFoundation Property Line LEACHING LINE ❑ No a& Length of linesTotal length/size FIL"TER:BED ❑ Distance to nearest: Well y Foundation Property-Line-w— - SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ �J 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§trict. 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 forwhich this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applican u II req coons. Complete drawing on reverses side. Signed X Title: -� -CJ- Date: FOR DEPARTMENT USE ONLY Application Accepted by Date T 7` Area Pit or Grout Inspection b Date Final Inspection by 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. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 FEEi INFO MOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMITNO. +.EH 13-24(REV.t/a5) J X r EH 14-28 T(J s.c