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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 11 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 �17 p� �bAff eZity rZ49'_- Lot Size PM Owner's Name e/K s� � AtiYress ,� -� r /�-!tJ � f' / Phone ! Q r Contractor License No. Pho TYPE OF WELL/PUMP: NEW WELL ❑~ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE r FOUNDATION AGRICULtOFfiff WELL'S` OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA -CONSTRUCTION SPECIFICATIONS ❑ Industrial �jj -- -L--WpenBottam.... —D..Manteca_�_,_y„„Qia.of_,Well_Excavation _ _ Dia. of Well Casing f tDomestic/Privd�te ❑ Gravel Pack ❑ Tracy Type of�Casing -E Specifications` ^ f'1 Public F1 Other Ll Delta Depth of Grout Seat Type of Grout I I Irrigation Approx. Depth .41 Eastern Surface-Seal Installed by rt. r 1 Repair Work Done L J� Type of Pump �0. H.P. ) State Work Done _ Well Destruction Well Diameter Sealing Material {top �D a`y Depth h ge"P A 17(0 Filler Material (Belot TYPE OF SEPTIC WORD: NEUV,II�STALLATION I 1 REPAIR/ADDITION l ]3 DESTRUCTION 1r'1 (No septic System permitted if public sewer is i �"'"'" '�available.witflin 200 feet.) installation will,serve:,9Residence_ Commercial— Other \t[ Y VA Number of living units Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TRfMENT PLT. ❑ ! Method of Disposal 4---m'"00—Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of tines ) Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS A I j Ll Distance to nearest: Well FounBation Property Line DISPOSAL PONDS ❑ ; I hereby cdrtity 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 Sart--Joaquin Local•Health-9i1trictc --- �----- ------ - - -- Home owrier',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 thelollowing: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- lion Laws of California." The applicant fo all to ctions. Complete drawing on raver Lside. w Signed X Title: Date: 71,101(0 1 FOR DEPARTMENT USE ONLY I Application Accepted by wowA%�L Date ` ` Area t Pit or Grout Inspection b Date��_. Final Inspection by • Date ) 3S Additional Comments: I 49�,A=aA �t� I 0 Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca a23-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i I FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PER NO. +.EHt3-24(REV. EH 3S-()(� 7 �1 EH 1a-26 v► v 1