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APPLICATION FOR PERMIT Ifto SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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 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. Job Address /n/100 Ey""' tCi f" '� Cit/'{) Lost Si�z.0eL^w PM ,Q r Owner's Name Q./�n nu2/$ Address /'7 / //N"1t4W L C77z'F Phone �ZZ Contract r� A Address�41 710 License No.J781Z P Phone)6Q 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 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r 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 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout_ — 1 1 Irrigation —Approx. Depth I I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Ile_ Material IBelow ') J TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR ADDITION DESTRUCTION t I INo septic system permitted if public sewer is available within 200 feet.l Installation will serve: Residence Commercial_ Other / G Number of living units: / Number of b rouoms 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 L LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS Depth Size Number r i SUMPS LI Distance to nearest: Well_df2— Foundation_Z0 r Property Line �5:: DISPOSAL PONDS ❑ �. e work will be done in accordance with San Joaquin county ordinances, state laws, and I hereby certify that I have prepared this application and that th rules and regulations of the San Joaquin Local Health D3trict. 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 compensa- tion laws of California." ) The applicant st 11 for all equ pd i cliionssl�CJomplete drawing on r rse side. Signed X C Title: Date: 61 �7u FOR DEPARTMENT USE ONLY P F, cvr; Date ' /!� 1S Area Application Accepted by -- _ 6l or Grout Inspection by - C�Da '1-3 Final Inspection by Bate @1' Additional Comments: f ❑ Stk t- Return ❑ Lodi 369ron ❑ Manteca 823-7104 ❑ Tracy 835-6385 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 CASH RECEIVED BY DATE PERMIT'NO. NFO /7� . EN 1}21 IREV.v x v -�7O FH 1138