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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 3 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit 10 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 ancL Regulations sof the Sawn' Joaquin Local Health District. S4tAt WILL 13c (rcSS T�Q/J S a !�"-�- F �Rf ' 19 Ib0tj,- S A sA c-r wrA Z4A . Ac- Job Address 4�" City Lot Size PM L (�� ^ Address _33 - Owner 'Z Owner's Name L Phoned� � .�/ fd w o pr}f,��1l�bt Y Contractor fir, ��` �n�s S Address too �� License No3773T:g Phone�3 TYPE OF WELL/PUMP: - "NEW WELL WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION)1 SYSTEM REPAIR ❑ OTHER ❑ / I DISTANCE TO NEAREST: SEPTIC TANK [ - SEWER LINES DISPOSAL FLD��rr ._--te PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL6._... PITS/SUMPS I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 6 +' ❑ Industrial 71Open Bottom C3Manteca Dia. of Well Excavation Dia. of Well Casing `;Rl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing ekrc Specifications 1-1 Public ❑ Other XDelta Depth of Grout Seal 2 Type of Grout I I Irrigation A00-Approx, Depth I 1 Eastern Surface Seal Installed by CO G 75K Repair Work Done ❑ Type of Pump H.P. l State Work Done— Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material i6elow 50'1 G - - TYPE OF SEPTIC WORK: NEW INSTALLATION I t REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is available within 200-feet.) Installation will serve: Residence— Commercial_ Other 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, 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 V SEEPAGE PITS I I Depth Size Number w� SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 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 I employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature I certifies the following:"I certify that in the performance of the work for which this permit is issued,l shall employ persons subject to workman's compensa- tion laws of California." � The applicant must call f r all r uired inspections. Complete drawing on reverse side. Signed X Title: Date: 3/6 P'd' - FOR DEPARTMENT USE ONLY Q Application Accepted by Date 3 11,5V Area_ �D Pit or Grout Inspection by DateFinal lnspection by !e ,&a. ate — Additional Comments: !� ► ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 4 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED SASH RECEIVED BY DATE PERMI7'NO. INFO Ids /� �0 3 f� �� vs f + EH 13-24(REV. w 51 �� 5-P-633 EH 14-2e