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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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. Job Address �� 1 i Cit Lot Size ' PM �� • �• - Y 4a�-J,eOwner-s1 a,C ap&`-z '_ , "•Address= Q 0 Phone Contract Address _L"- �iP ! License No a 13 CePhone3(09-5, 10-5 TYPE OF WELL/PUMP: ''"- NEW WELL" ❑ Wit. WELL REPLACEMENT ❑ DESTRUCTION ❑ Y PUMP INSTALLATION ❑ r SYSTEM REPAIR ❑ OTHER ❑ DISTANCE z0 NEAREST: SEPTIC TANK -SEWER LINES DISPOSAL FLD. _ PROP. LINE � s 41 ' -?'°;FOUNDATION t AGRICULTURE WELL OTHER WELL PITS/SUM . INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS a t i , ❑ Industrial ❑ Open Bottom z❑-Manteca— Dia. of Well Excavation Dia. of Well Casing _ x� •.❑.Domestic/Private ❑ Gravel Pack, _❑_Tracy Type of Casing Specifications t f1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout — I Irrigation C�Approx.�Depth'k l I Eastern Surface Seal installed by ee- Repair Work Done ❑ Typeo f Pump,, H.P. ate Work Done Well Destruction ❑ N-Well Diametei' Sealing Material {top 501 Depth le Material (8elow,50'.), TYPE OF SEPTIC WORK,, NEW INSTALLATION I1 REPAIR_ ADDITIO d DESTRUCTION I I (No septic system permitted if public sewer is d variable within 200 feet.) 1^ Installation will serve: Residence Commercial.>1�>. Otherrli -�rl�tA cQ Number of living units: Number o�-bedroo s ' Character of soil to a depth-of-3 feet•'- '. _+ _ Water table depth Q+ l SEPTIC TANK ❑ Type Mfg '` Capacity No. Compartments ,PKG.,TREATMENT PLT. ❑ .. Method of Disposal 4 ' Distance to nearest !Nell -- Foundation--» Property Line LEACHING LINE 'L1 No.&'Length of lines L i Total length/size - FEL' E4 6ED`. � CI Distance;io nearest: Well Foundation Property Line 4 • � r 6 SEEPAGE' . I�Depth _a�j Size �� Num er, SUMPS-- :- -�l -Distance to nearest 1111e11 SC!t F undation Q':`� Property Line DISPOSAL PONDS ❑ �~ I hereby certify that I have prepared this,application and that the-work will-be done in accords cn a 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 cerfifie`s the fol16wing:-"1 certify that in the performance of the wdrk for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." Theapplicant ust call fo II re uired inspections.`Complete-drawing-on-reverse-sid ! Signed X Title: Y Date: FOR DEPARTMENT USE ONLY ' Application Accepted 6y Dater— , Area 3 .yam/ or Grout Inspection by Da aFinal inspection by �' f�Date f7 (./ Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca„823.7.104 r . ,-❑TracY_836-.6386,„, -- Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. + EH13-24{AEV.r i x 57 ` 7 � EH 14-29 L - ., ' '�' �' ��