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APPLICATION FOR PERMIT F SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 I� PERMIT EXPIRES .1 YEAR FROM DATE ISSUED g�(o1ri T plete in Triplicate? ® j—3o � 7Z J ^Y: A� I"y'."�f - y 4'_t.. Y Application is hereby made to the San JoaquI Local Health past icf 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 Ruies and Regulations of the San Joaquin Local Health District. Job Address CityLot Size PM Owner's Name ARW Address ZO Phone2' ,6 a Contractor's Name CIAME 0 License No. _ _ Pho �� TYPE OF WELL/PUMP: NEW WELL E3 WELL REPLACEMENT Ll DESTRUCTION 4u PUMP INSTALLATION ❑- SYSTEM REPAIR ❑ OTHER ❑ I� 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 I� 1 ❑ 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 --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work pone ❑ Type of Pump H.P. State Work Done ` Weil Destruction ❑ Well Diameter Sealing Material (top 501 it f 4 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) II installation will serve: Residence_ Commercial_ Other i 'r Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth l SEPTIC TANK ❑ Type/Mfg _ Capacity No. Compartments f 1 l PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line ;� t LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line it i SEEPAGE PITS ❑ Depth Size Number ii p SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ [ 1 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 V rules and regulations of the San Joaquin Local Health District. II l 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." .11 The applicant mu call for all fired inspections. Complete drawing on reverse side. I� Signed X__ Title: Date: �lA Av �i FOR DEPARTMENT USE ONLY Application Accepted by Date G AeD _�i Pit or Grout Inspection by Date Final Inspection by te5 � l Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-M Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEEn INFO AMOUNT DUE AMOUNT REMITTED C RECEIVED BY DATE PERMIT"NO. I� + EH13-241REV.10/63F EH 14-26 �� ®O bZSS / ai