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APPLICATION FOR PERMIT SCANNED SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 (� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i (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 oc No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. i Job Address [ I 7 �^–'r , �/ City` Lot Size PM Owner's Name �✓ Address Phone Contractor 1A )! t a Address 4 () ticense No.A'30w Phone 99,Z5,1, I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT El DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 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 Cl Domestic/Private ❑ Gravel Pack Cl Tracy Type of Casing Specifications . 11 Public . II Other Cl Delta Depth of Grout Seai Type of Grout--.---. I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') i- Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION I RUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: R sidence Commercial— Other Number of living units: Number of bed/rooms Character of soil to a depth of 3 feet: C L,r-1, I L6A ivy _ Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT, ❑ Method of Disposal Distance to nearest: Well Foundation Property Line 7 LEACHING LINE �fV"O. $ Length of lines r T tel lengthlsize FILTER BED ❑ Distance to nearest: Well Foundation / Property Line SEEPAGE PITS Depth Size Number' SUMPS Ll Distance to nearest: Well - Foundation 4 Property Line 42 DISPOSAL PONOS ❑ iZC)" 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 certif a following'- ollowing: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion taws o lifor,ia." The applican .mu al!a.1qu din ctia s. m lete�r�wing o averse sid . F� Signe ills: Data: FOR DEPARTMENT USE ONLY r Application Accepted by '" r Date Area Pi or Grout Inspection ir' ate Final Inspection b Date Additional Comments: 0 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, Silk., CA 95201 FEEINFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED aY DATE PERMIT'NO. + EH 13-24IFFEV.4/1451 C/ EH 14-26 � / F J w