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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRTUT 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 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 /. , City Cf osw .t Size I o / M Owner's Name Address /�� h 'zC e Contractor Addreq 17 License No. 7 Phone 4(0 G v Z TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION [P�- 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 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F�1 �Public ❑ Other ❑�Delta Depth of Grout Seal Type of Grout I�f'1rrlgation Approx. Depth WEastern Surfaaccef Seal Installed by /�j" Repair Work Done (I/Type of Pump �, / L• H.P. _6�/ State Work Done_/i'/S1'A L Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I 1 DESTRUCTION I 1 (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial Other Number of living units: 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 and n Property Line LEACHING LINE ❑ No. & Length of lin s Total length/size FILTER BED O Distance to neares : Well Foundation Property Line "7 SEEPAGE PITS 11 Depth ize Numbe _ SUMPS Ll Distance to Weare Well _ Foundation PropeLine DISPOSAL PONDS C1 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, an , rules and regulation San Joaquin Local Health District. Home owner or ensed age is signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any p s in such anner as becrmuject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the ollo ng: "I rtify t at i the ce of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws f Calif rn' . The app cant st c for n ctions. e e drawing on ri cle. Signed �Q Title: .� Date: T / R DEPARTMENT USE ONLY + l Application Accepted by LA A _ Date �� Q �1� Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ 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, Stk., CA 95201 '�I1N■rEE AMOUNT DUE AMOUNT REMITTED (�C K 4 RECEIVED BY DATE. PERMIT NO. • EH 14-2B►REV.ti H51 WW-\ I A�: