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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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 , `)� r" yoc)1 l City G40C 1��k';2"l Lot Size PM Owner's Name Oct -Yl r), �-t F r t;t Address J M` re Y%- Phone Contractor T 00 tr Address 1 S Ay- 1'1C31 d License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 9F' �.l lr A C 1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE c:10drt nth FOUNDATION AGRICULTURE WELL OTHER WELL "PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS _ Industrial / i1 ' -S Ovr� �!d `Open Bottom ❑ Manteca Dia. of Well Excavation i -1 lr!l` / �-- Dia. of Well Casing �.•'❑ Domestic/Private TGravel 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 Done O Type of Pump H.P. State Work Done Well Destruction ❑ -Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTAL\bedr REPAIR/ADDITION u DESTRUCTIO C (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ _ Other Number of living units: Number Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg /ndation ty No. Compartments PKG. TREATMENT PLT. O Method of Disposal Distance to nearest: Well F Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Fou ation Property Line SEEPAGE PITS ❑ Depth Size ,Number SUMPS C1Distance to nearest: Wel' Foundation Property Line DISPOSAL PONDS O a 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 rules and regulations of the San Joaquin Local Health District. 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." The applicant most call for allp required inspections. Complete drawing on reverse side. Signed Title: ' "�.c !f� �� r t Date l—I— '1, ..12c� 1 ORDERTMENT USE ONLY Application Accepted biiLt� /�' Date ��L� "�� Area Pit or Grout Inspect y Date Ficial Inspection by Date Additional Comments Q� EPI ❑ Stk 466-6781 ❑ Lodi 369-k2i ❑ Manteca 823-7104 VO TFacy 835 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY INFO CASH DATE PERMIT"NO. t EH13-24(REV.I/a5) t L, EH 14-26 i �