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n • APPLICATION FOR PERMIT a SAN JOAQUIN LOCAL HEALTH DISTRICT _ 1601 E. HAZEL i ON AVE., STOCKTON, CA J R Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED lComplete 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 II made in compliance with San Joaquin County Ordinance No.549 lot sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address CRV6"eZ Lot Size PM i, Owners Name 44d-9 Address _ Phone Contractor Address & 94 License No. Phone TYPE OF WELL/PUMP: NEW WELL CIWELL REPLACEMENY❑ DESTRUCTION ❑ PUMP INSTALLATION-❑ SYSTEM_REPAIR X ` 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 AR€A CONSTRUCTION SPECIFICATIONS ❑ Industrial C7 Open Bottom ❑ Manteca Dia_ of Well Excavation Dia. of Well Casing ? Domestic/Private ❑ Gravel Pack-. ❑,Tracy . rte.—Type.of-Casing SpecifiralionS � I t Public n Other n Delta Depth of Grout Seal Type of Grout I t Irrigation - —ApplM.•Depth I I Eastern rSarface Seal Installed by _ i Repair Work Done ❑ Type of Pump H.P. LV2- State Work Done - WAO Well Destruction ❑ Welt Diameter _T Sealing Material ftop 501 Depth Fr1ler Material (Below 50 TYPE OF SEPTIC WORK: NEIN INSTALLATION I I REPAIR/ADDITION I I 'DESTRUCTION I 1 (No septic system permitted if public sewer is s available within 200 fast.) Installation will serve: Residence, Commercial_ Other b Number of living units: Number of bedrooms. --_-- Charactar•of soil to a depth of 3 feet: r ( : Water table depth SEPTIC TANK D Type/Mfg - /'' Capacity No. Compartments y PKG. TREATMENT PLT.❑' + ' Method of Disposal V r Distance to nearest: Well Foundation Property Line .. ,...-.rte••,� .. LEACHING LINE ❑ No. & Length of linea Total langth/size FILTER BED ❑ Distance to pearest. Well_ Foundation :Property Line 1 SEEPAGE PITS I I Depth Size Number i- --sumps Well A Foundation- -PropertyVne— DISPOSAL PONDS ❑ t ''■ r 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 i rules and regulations of the San Joaquin Local Health DilittICL 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, 1 shall not employ any person in such manner as to become subject to workman's compertsation laws of California.,,Contractors 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 must call for all required in ctionsl orn a drawing on reverse side. Signed Title: Date: OA ARTMENT E OfifLY Application Accepted by - Date '3 Area [r) Pit or Grout Inspection by Date Final Inspection b.T,T-\ Additional Comments: r 0 Stk 456-6781 ❑ Lodi 3W3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 ' Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2609, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED ISH RECEIVED BY DATE PERMIT Nt). I • EHM24IREV.tins7 ^�� Y5 til t4•�