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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE4TON 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 Distrito./ / �' l ,lob Address � _"/6 �` ' c=n �� ZZ 0& - City /1�• Lot Size PM Owner's Name Address Phone Q pp � t,�t9TE� Contractor �s Address � w L-GD License No.�,C_�Phone rl TYPE OF WELL/PUMP: �`, NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION iZ/{eA�YSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE t FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF.WELL --PROBLEM AREA -CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ 0 en Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing �Domestic/Private El 'ravel Pack ❑ Specifications Type of Casing C1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation AILIApprox. Depth ❑ Eastern Surf Seal Installed by Repair Work Done 13Typ1 of Pump _S U H.P. I�Z— State Work Done� pG E rJc FFCTj Well Destruction ❑ � WeII,ll Diameter SealinL Material (top 50') —� � 2,TH Wd-_7 42 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ ,Ft AIA/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is I` available within 200 feet.) Installation will serve: Residence` Commercial— Other Number of living units: jL Number of bedrooms �S1 r Character of soil to a depth;Jof 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments , PKG. TREATMENT PLT. 1-1Method of Disposal Distance to nearest: Well Foundation Property Line I LEACHING LINE ❑ �No. & Length of lines Total length/size FILTER BED LJ Distance to nearest: Well Foundation Property Line E7 SEEPAGE PITS ❑ Depth Sized r M11'umbe� ' SUMPS FI to nearest: Well Foundation ry M Pr.perty.Lme DISPOSAL PONDS ❑ . L hereby certif" at 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'District. t_�__ . Home owner or licensed agerk's signature certifies the following: "I'certify that in the performanc�of the work for which this permit is issued;i shall'not` employ any person in such manner as to become subject pensa ion'laws"o"f�Cal'rfarnia."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." .I1' 11 The applicant mu c It or E requir inspections. Com tete drawing on v�rs side, Signed a I Title: Date: f FOR DEP- .HENT U ONLY Application Accepted by Date �` Area / —/6/Jg? I�. Al Date Pit or Grout Inspection by Date— -� Final Ihspect7o by Additional Comments: --------B-Stk--466=6781 - ❑-Lodi-369-3621`` '❑'Man4eca'823-71di1 ❑ Tracy Applicant - Return all copies to: Environmental Health Permit/Services 1601 E..HazeltonAve., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVD BY DATE PERMIT NO. INFO Ise + EH 13-24(REV.1/e 5) �,� EH W28