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i *.. y APPLICATION FOR PERMIT k 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 (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 welllpump and the Rules and Regulations of the San Joaquin Local Health District. Job Address � Gty Lit Size PM 2LAOwner's Name �� Address .- / L?YLy� Phone Contractor /l ss License Na. x Phone9'y3_�5/Z TYPE OF WELL/PUMP: NEW WEV ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ " PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS f: Y INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open-Bottom ❑ Manteca -Dia: of-Well-Excavation r , Dia..of.Well Casing C] Domestic/Private ❑ Gravel-Pack ❑ Tracy, Type of Casing Specifications M Public n Other� F7 Delta! Depth of Grout Seal Type of Grout I Irrigation _-Approx.:,Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H,P. State Work Dane Well Destruction ❑ Well Diameter Seating Material (top 501 Depth ; Filler Material {Below 50') f TYPE OF SEPTIC WORK: NEW INSTALLATION I:] REPAIR/ADDITIOV 11 PESTRUCTION.1 I Mo septic system permitted if public sewer is availab 19OWithin 2C9 feet.I Installation will serve: Residence Commercial— Other Number of living units: Number of bedrooms : Character of soil to a depth of 3 feet} f Water table depth a SEPTIC TANK El Type/Mfg Capacity No. Compartments PKG'TREATMENT PLT. ❑ Method of Disposal t {I Distance to nearest: Well Foundation Property Line jT LEACHING LINE-,e ❑ No. & Length of lines - Notal length/size r FILTER BED " ❑ Distance to nearest: Well oundation Property Line SEEPAGE ATS__ "` 11 Depth ; Size V Number SUMPS L7 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I heteby certify that I have prepared this application and that the work will be done in ac rdance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquih Local Health District. Home owner or licensed agent's signature certifies the foilo�W".-�l_certify-that-in t rmanc of the work for which this permit is issued, I shall not employ any person in such manner as td become subject to workman's compensav . urs�f Calif mia."Contractor's hiring or sub-contracting signature certifies the fallowing: "I certify that in the perforn�nce of the work for which this pern1h-is issued, I hall employ persons subject to workman's compensa- tion laws of California." I The applica ust call foral quired i spections. Complete drawing on reverse side. J n Signed X r Title:�� _ Date: CJS (}J( FOR DEPARTMENT USE ONLY " i' Application Accepted by Date*' `�� ' Area 0 �f Pit or Grout Inspection by Data Final Inspection by t; �G-.rM N`� Date r Additional Comments: rt - ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE A�MODUNT� REMITTED CASH RECEIVED BY DATE PERMIT'NO. +.EH13-241REV.t N51 375 EH 1426 �'V