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APPLICATION FOR PERMIT M'• SAN JOAQUIN LOCAL HEALTH DISTRICT I 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466.6781 PERMIT EXPIRES 1-YEAR FROM DATE ISSUED (Complete in Triplicate) Application is haleby 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 far well/pump and the Rules and Regulations of the San Joaquin Local Health District. Jab Address r CityLot Size PM Owner's Na4K5:jAj6resSJV Address ?� " ' Phone Contracts / License No Phone d TYPE OF WELL/P MP: NEW WELL -• WELL REPLACEMENT ❑ DESTRUCTIOND PUMP INSTALLATION ❑ ISYSTEM REPAIR ❑ OTHER ❑ 1 DISTANCE TO NEAREST: SEPTIC_TANK SEWER LINES a DISPOSAL FLO. - 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 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1 FI Public ❑Other ❑ Delta ' Depth of Grout Seal Type of Grout •J I I Irrigation —Approx. Depth I I Eastern •....r..,Surface Seal Installed by Repair Work Done ❑ Type of Pump - H.P. +-'x State Work Done_ T Well Destruction ❑ Well Diameter Sealidg`Material (top SO-) r. Depth Filler Material(Below 50'1 • TYPE OF SEPTIC WORK: NEW INSTALLATION" I.1 DESTRUCTION No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence v Commercial_ Other r Number of living units: Number of bed s. - Character o1 soil to a dep�3 feet: ' E Water table depth SEPTIC TANK ❑ Type/Mfg Capacitirl No. Compartments PKG.TREATMENT PLT. ❑ Method of Disppg�/I Distance to nearest: Well� � Foundation _ Property Line --ta--+� LEACHING LINE ❑ .No. 8 Length.of lines ��-t-�-- Total length/size ` FILTER BED ❑ Distance to Dearest: ell/An__ Foundation Property Line SEEPAGE PITS I'1 DepthSize Number SUMPS ❑ Distance to nearest: Well Founclarm Property Line , DISPOSAL PONDS ❑ 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 w 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 41 employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature 1 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 compensa- tion laws of California." The applicant 1 rust or all req u�E tions. Comp drawing on r arse side. /� �� Signed X Title: ��GL,t-'yam-- - Dam, /,/ - 1 FOR DEPARTMENT USE ONLY q Application Accepted by ,/ ' // `fir 9�1 ,[ter Date r'J res Pit or Grout Inspection by Date Final Inspection by Zk Data 7 Additional Comments: • ❑Stk 466-6781 ❑ Lodi 369-3521 ❑ Manteca 823-7104 ❑ Tracy 8354385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 9=1 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. w EH 13-24(REV.1/x 5) EH Mail