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AWN APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA L. Telephone (209) 466-6781 n 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 Cou_nty,Ordinance"No.549 for sewage or No. 1862 foT.well/pump and the Rules and Regulations of the San Joaquin Local Health District. w. " � ��ff l Job Address 9 � �LCJiO�i� �- //es(�" " w City Lot Size ko00 PM IOwner`s Name f k ��ir�T fr/l�-� Phone ress 1 Contractor d ass v License No. d* Phone TYPE'OF WELL/PUMP: NEW LL ❑ WELL REPLACEMENT ❑ DESTRUCTION o❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ -` OTHER-0 k 11 IS'TANCE TO.NEAREST: SEPTIC TANK SEWER LINES "-y ! DISPOSALTLD. ' �. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL' PITS/SUMPS INTENDED USE TYP.E'OF WELL PROBLEM AREA—CONSTRUCTION SPECIFICATIONS r ❑ Industrial ❑ Open"Bottom ❑ Manteca Dia. of Well',Excavation I Dia. of Well;Casing ❑ D mestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public 3 ❑ Other ❑ Delta Depth of Grout Sea! Type of Grout ❑ Irrigation ! ___Approx Depth ., ❑ Eastern Surface Seal Installed by # r Repair Work Done ❑ Type of Pumptx H.P. State Work Done_ 4 Well Destruction ❑ Well Diameter Sealing Material (top 50') ? �V I y Depth} { `" Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION D" REPAIRIADDITION ❑ DESTRUCTIO (No septic system permitted if public sewer is }� j avail ab�within'2 feet.) Installation will serve. Residence�icomrnercial—� 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 j I PKG. TREATMENT PLT. El s; Method of Disposal I I Distance to nearest: Well Foundation-_-----—Property-Line ,.f_. LEACHING LINE ❑_�Na:&Length of_linesn 5 Total length/size ! ' I FILTER BED ❑ Distance to nearest:" Well Foundation Property Line' , "SEEPAGE PITS ❑ Depth ? Size Number l SUMPS ❑. Distance to nearest. Well Foundation l Property Line DISPOSAL PONDS ❑, {'.! ! 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 rules and regulations"ofithe San Joaquin Local Health'District. I j" 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 became.subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa tion laws of fornia.": t The applica ust call for all requ" inspections. Complete drawing on reverse side. j Signed X Title: Date: FOR DEPARTMENT USE ONLY G Application Accepte2y? a Date 4 �� Area Pit or Grout Inspecti Date Final I action by '� Date -3 �7 Additional"Comment's: 3 �- ` 0 . ❑ Stk 466-fi781 m__✓ ❑"Lodi 369-9621 ❑'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 1 _ FEE AMOUNT DUE AM NT REMITTED CASH CK RECEIVED BY DATE PERMIT'NO. INFO + EHI13-241REV.-i/ns) EH'1428