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M' q APPLICATION FOR PERMIT !� SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA it Telephone (209) 466-6781 PERMIT EXPIRES YYEAR FROM DATE ISSUED �3 (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. 1 Job Address ?" � �. f ,',• ""�' City Lot Size PM Owner's Name Address Phone f ii Contractor � — Address e.—ti"b ' ense No. 91d�4-d_& Phone TYPE OF WELL/PUMP: NEW WELL L.1 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ fi DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE :I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 'A.DomesticlPrivate ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'l Public 171 Other CI Delta Depth of Grout Sea! Type of Grout I I Irrigation Approx. Depth i I Eastern //f Surface Seal Installed by _ Repair Work Done Type of Pump�;;Q ZL�T H.P. /&= State Work Done ; Well Destruction 0 Weli'Diameter Sealing Material (top 50') Depth __Filler Material IBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I.) REPAIR/ADDITION I I DESTRUCTION'[')1hlb-seplicsystern permitted if public sewer is i[ 1! Iavailable 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. CompXZ PKG. TREATMENT PLT. ❑ �., Metho Distance to nearest: Welles Foundation Property Lir LEACHING LINE ❑ No. & Length of lines ' Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line ENTAt HEALTH ENVIRC SEEPAGE PITS 11 Depth Size-�' I _ Number 1 I I PERMITISERVIC c SUMPS ❑ Distance to-nearest:x_._Well° Foundation Property Line DISPOSAL PONDS ❑ 1 I 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 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 the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compens tion laws of California." II t The applican ust all for quired inspections.-Complete drawing on reverse side. // g j Signed Title: a4!A___ Date: FOR DDEPPAR MENT USE ONLY Application Accepted by Date 'Area " ly - I Pit or Grout Inspection by Date Final Inspection by Date g� Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6365 I Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 Il FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT"NO. INFO CASH_. a.EH 13-241REV,1/851 �S`a� � ' A• ' 7�,� ��"� EH t4-26