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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE.; STOCKTON, CA Telephone (2091'466-6781 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 Ryles and Regulations of the San Joaquin Local Health District. Job Address Ci Size PM Owner's Name ` Address _ v Phone Contractor L V ess P6 r License No. hone 1-4 TYPE OF WELL/PUMP } NEW WELL ❑. WELL REPLACEMENT ❑ DESTRUCTION ❑ t }�PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER DDISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION 'AGRICULTURE WELLS � OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS / ❑ Indud I ❑ Open Bottom E] Manteca Dia. of Well Excavation Dia. of Well Casing domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing- ` Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation _ ��4pprox. Depth / ❑ stern j urface Seal Installed by Repair Work Done L1Y Type of Pump % e H.P.J .- State Work Done_ 91c, 40 L/c J Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATION ElREPAIR/ADDITION El ❑ (No septic system permitted if public sewer is U available within 200 feet.) Installation will serve: Residence, Commercial— Other LA Number of living units: Number of bedrooms J Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS I hereby certi at Iofthe have prepa this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and r lations San J aquin Local Health istrict. Home o er or licensed agent's si ature certifies th ollowi I certify that in the performance of the work for which this permit is issued, I shall not employ ny person in such manne as Io become su to ork an'a com tion laws of California."Contractor's hiring or sub-contracting signature ceniZe the following:"I certify at' the pe rm c o e w rk for w ch this per tis issued, l shall employ persons subject workman's compensa- tion I s of California." The plicant must al r ired ins cti ate drawing re d SigneTitle ate: C J FOR DEPARTMENT USE ONLY Application Accepted by Date " Area / Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6365 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 CASH RECEIVED BY DATE PERMIT'NO. + EH 13-241REV.I/a5) S`, Cn. -71 EH 1426 s