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APPLI ATION FOR PERMIT f SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAMILTON AVE., STOCKTON, CA Telephone (209),466-6781 ry " PERMIT EXPIRES 1 YEAR FROM DATE ISSUED.. • ,t, .�, y iComplete in Triplicate) r rin 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. 1.862 for well/pump and the Rules and Regulations of.the San Joaquin • Local Health District. �� ` Job Address 2_375 �R c v ;� City Ti C Lot Size /V� PM µ Owner's Name Address Phone r AJ ` Contractor (7 QC ! U_ Address ��r lit 14TJ1l_TLicense No. C.aRltone Z TYPE OF WELL/PUMP: NEW WELL 06, WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Z ro $.i Industrial 4i?,Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private 4KGravel 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 ❑ Type of Pump H.P,Sur o-c�5 Q c,,i tete or one Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is " available within 2D0 feet.) Installation will serve: Residence_ Commercial— Other Ms Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: ' Water tat3le depth SEPTIC TANK ❑' Type/Mfg I. Capacity - No. Compartments PKG. TREATMENT PLT. ❑ s Method of Disposal Distance to nearest: Well Foundation Property Line i LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well - Foundation Property Line SEEPAGE PITS ❑ Depth Size i Number SUMPS ❑ Distance to nearest: Well Foundation 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 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." e The applicant must call for all required inspections. Complete drawing on reverse side. r Signed K Title- Date: �S4/�fl4 r yh FOR DEPART NT USE ONLY 3j e ` Application Accepted by Date a Z�"�� I �"-_ Pit or Grout Inspection by Dat-z� 4nal Inspection by Date Additional Comments: ❑ Stk 466-Ml ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 83544 ' 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 RECEIVED BY DATE PERMIT'NO. INFO , CXgn +EH 13-24(REV.1/a 5) EH 1426 S� 4