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k n Y APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE 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 h �descriThis 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 o e San Joaquin Local Health District. Job Address City Lot Size PM Owner's Name — �� AddressPhone a! '. Contractor Address 57 License No._� -d4W Phon TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ �^ 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 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ~ ❑ Irrigation ----4pprox- Depth ❑ Eastern Surface Seal Installed by W Repair Work done ❑ Type of Pump H.P. Slate Work Dane f" �^ Wel! Destruction ❑ Well Diameter Sealing Material (top 50') � Depth Filler Material (Below 50'I TYPE OF SEPTIC WORK: NEW INSTALLATION Cl REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) i Installation will serve: Res&ncelc— Commercial Other s Number of living units: A,t 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 J. LEACHING LINE ❑ No. & Length of Lines Total 1l ngth/size FILTER BED ❑ Distance to nearest: ` :'Well _ Foundation :Property Line SEEPAGE PITS ❑ Depth Size Nyrtlber SUMPS Ll Distance to nearest: Well Foundatibr� Property Line DISPOSAL PONDS ❑ l / I hereby certify that I have prepared this app ication and that the work will be done in accordance with an Joaquin county ordinances,state laws, and - rules and regulations of the San Joaquin Local Health District. Horne 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 li 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 applican t call fora d inspections. Complete drawing on reverse side. { Signed)LTitle: ��>/� „ „ bate: Application Accepted by FOR DEPARTMENT USE ONLY Date 2~ Area 2 _ r Grout ins/p�ction by Date l! Final In by Date :�—Z ��/" rr Add,tlonal Comments: `r ❑ 5tk 466-6781 Lodi 3 -3621 ❑ Manteca 1323-7104 Tr y. 835 Applicant- Return all copies to: Environmental Health Permit/Services 16011E. Haz Eton Ave., P.O. Box 2009, Stk., CA 95201 INFO AMOUNT DUE AMOUNT REMITTED �e CASH RECEIVED BY DATE PERMIT'NO. + EH M24 MEV,1 5) �--7 1 EH 14-26 /0 Oaf �G�pc� L© i ( �LV�--;- —30�