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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 (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. � 1/�� Job Address Ccopl J�-K CityA-4menLot Size • PMy Owner's Name _-_Clydte 4A_ 00- Address 00 1 uto I&S'h4 )4,i� ^/-��' Phone 36q Q�7 -- /� ,. Contractor � IL—Address- "7�i1` U / �.��td� a/c� License No. t5-2 Phone 339-W-36 TYPE OF WELL/PUMP: NEW WEL WELL REPLACEMENT ❑ l DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ � OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK r�� -- SEWER LINES �� DISPOSAL FL1310," PROP. LINE Z5 FOUNDATION _ AGRICULTURE WEL-L ' OTHER WELL _r-PITS/SUMPS 7� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 01 ndustrial Open Bottom ❑ Manteca iDia. of Well Excavatign Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casin 3 �]'s �� Specifications jO�V n Public ❑ Other ❑ Delta Depth of Grout Seat -s� � Type of Grout � I I Irrigation Approx. Depth l 1 Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of P H.P. State Work Done�� Well Destruction ❑ iameter Sealing erial Itop 50') i Depth Filler Weateriai (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION i I DESTRUCTION I ] INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 fget: Water table depth SEPTIC TANK ❑ Type/Mfg ` Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distant o nearest: Well Foundation Property Line LEACHING LINE ❑ No. R Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ( I Depth Siz Number SUMPS Cl Distance to nearest: ell Foundation Property Line DISPOSAL PONDS ❑ 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 shalt not employ any person in such manner as to become subject to workman's compensation laws of California." Contractors 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 Califor The applicant ire pspe omplete drawing on reversside. f Signed X / Title: �',. Dat 2 !� _FOR DEPARTMENT USE ONLY /+� pplication Accepted by Dat ef� �! r� Area V�] Pit or Grout Inspection by Date 44 AA Final Inspection by Date Additional Comments: A411 a-tJa.,6 ❑ Stk 466-6781 ❑ Lodi -3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave„ P,O. Box 2009, Stk., CA 95201 FEEAMOUNT DUE AMOUNT REMITTED CK INFO CASH `RECEIVfD BY �7 DATE PERMIT NO. a EH13-24(REV.I/H5) EH 14-28 L 4'iii✓✓✓ C�• 77f��