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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 { PERMIT EXPIRES 1 YEAR FROM DATE ISSUED j 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 i made in compiiance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for weilJpump and the Rules and Regulations of the San Joaquin Locat Health District, 4 7S ) rao'l CVutil" City r L Lot Size X 1 PM Jab Address /� 7 y Owner's Name ]' '''t ,af t'�5 Address — L% . �G X -- Phone 32.►AlF,": id c7d Ski=�z -1ci.. d-o w,- ,_ CcJ S . te+{L L C r2 7 R 0 Phone 55L- -7 Contractor tV{'qtr �x }O�R� Address I (oLicense No. ` TYPE OF WELLIPUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR © OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 50 DISPOSAL FLD. PROP. LINE FOUNDATION AGRicuLTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �,PtC. [1f6 dle Sint 5) L� Industrial ❑ Open Bottom a Manteca 0ia. of Well Excavation Dia. of Weil Casing n Domestic/Private Gravel Pack 'XTracy Type of Casing, Specifications I'i Public 091F- ;dit VA n Other n Delta Depth of Grout Seal Type of Grout I I Irrigation ^'��-Approx. Depth t I Eastern Surface Seal Installed by lir_ ^ 416.( � r - �'� Repair Work Done L] Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50'1 �- Depth Filler Material i8elow 501 F SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION I I "iNo septic system permitted it public sew l available within 200 feet.) Installation will Residence, Commercial_ Other Number of living units: umber of bedrooms Character of sail to a depth of 3 feet: er table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments . PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well ation Property Line LEACHING LINE ❑ No. 8 Length of linesgth/size FILTER BED ❑ Distance t est: Well Foundation "Pro ine SEEPAGE PITS Depth Size Number SUMPS L� Distance to nearest: Well Foundation Property Line SAL 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, 1 shall not employ any person in such manner as to become subject to workman's compensation laws of Califomia."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 st call for all required inspec`t'ion. Complete drahrin e�"t�on reversA side. Signed X_ �'^�' ��l PG�+��' Tg;a.VL' Hca{1Q3{J Date: 4 FOR OEPARTiMENT USE ONLY �r Z� C y v Application Accepted by 7�Y Date Area ` t f r - Pit or Grout Inspection by Date Final Inspection by " Oatet�"! Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 " ❑ Manteca a23=7104_ ❑ Tracy 83S-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazeiton Ave., P.O. Box 2009, Stk., CA 95201 L1 ! FEE AMOUNT DUE AMOUNT REMITTED CKRECEIVED BY DATE PERMIT"NO. _ INFO CASH' ,7 ,r, r . EH 1326 1REV.1 i w 5) y�L�^ b' /.`,j` r ,r� Y ;-L,1 ��-, (�' "r• (r._t EH 1426 �1 r 1 �( y �!' /J