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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT . 1601 E HAZEL i ON AVE , STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES I 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 545 for sewage or No 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District Job Address City ) Lot Size PM Owner s Name Address � 2 �n.r�Ls.da .-. 7 - Phone Contractor ddress 319 940 t PL 150&2 License No Phone TYPE OF WELL/PUMP NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION ❑ PUMP INSTALLATION ❑ 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 C ❑ lndustriak ❑ Open Bottom ❑ Manteca Dia of Well Excavation Ora 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 Sea] Installed by Repair Work Done ❑ Type of Pump H P State Work Done Weft Destruction ❑ Well Diameter Sealing Material (top 50 ) Depth Filler Material (Below 50) Onstallation - available within 200 feet JPE OF SEPTIC WORK NEW INSTALLATION ElREPAIR/ADDITION 3K DESTRUCTION ❑ (No septic system permitted if public sewer is will serve Residence_ Commercial X Other 1 Number of living units Number of bedrooms Character of sod to a depth of 3 feet - - Water table aepth SEPTIC TANK ❑ Type/Mfg Capacity i<siQ _ No Compartments L{ PKG TREATMENT PLT ❑ Z Method of Disposal Distance to nearest Well Foundation_A0_:__ Property Line LEACHING LINE ❑ No & Length of lines Total length/size FiLTER BED ❑ Distance to nearest Well Foundation Property Line SEEPAGE PiTS J& Depth - --Size Number i SUMPS ❑ D%ranae to nearest Well Foundation_ /moi Property Line DISPOSAL PONDS ❑ 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 foflovving I certify that in the performance of the work for which this permit is issued € 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, l shall employ persons subject to workman s compensa- tion laws of California The applicant must call for ail required inspections Complete drawing on reverse stae 7 Signed X FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection Dy Date Fina: inspection by Data Pditional Comments 47G GL 114-1- Stk 466-6781 ❑ Lobi 69-3621 © Manteca BM 7104 ❑ Tracy 835-6385 Applicant- Return all copies to Environmental Health Permit/Services 1601 E Hazelton Ave , P 0 Box 2009 Stk , CA 955201 FEE AMOUNT DUE AMOUNT REMITTED CK# RECEIVED 5Y PATE PERMIT NO INFO CASH H 1324{REV t/a5) ��y77� E i:H 14-26 /$ ,J