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E _ APPLICATION FOR PERMIT ' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA L Telephone !2091 466-6781 Ay �� 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. IB62 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. .I Job Address �` � =-�`�✓�� `� City ��'�^ Lot Size PM r Owner's Name Address 3 • `�� Phone Contractor 34Gtil�-Addr...PO 61'W - ©/ License No E f6;'- Phone TYPE OF WELL/PUMP: NEW WELL ❑ yWELL 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing .Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications FI Public ❑ Other I H Delta Depth of Grout Seal Type of Grout I I Irrigation _.Approx. Depth l I EasternJ Surface Seal Installed by Repair Work Done ❑ Type of PumpQJj_ . [ — H.P. Pj State Work Done I Well Destruction ❑ Well.Diameter_-, -"'Sealing Material (top 50'1 —Depth - -- - _Eiller„Material_IBelow 50'1_ _ TYPE= OF SLPTIC WORK: NEW INSTALLATION ['I REPAIR/ADDITION [ I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) V1 Installation will serve: Residence Commercial_ Other i i Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK _ O- Type/Mfg c Capacity No. Compartments PKG. TREATMENT PLT. ❑ 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 I i Depth n Size Number I SUMPS ❑ Distance to nearest: Well Foundation I Property Line fDISPOSAL PONDS Elt: ' 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. t I 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 I 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 must c I for all requir d inspections.-Complete drawing on reverse side. l pI Signed X Title: R DEPARTMENT USE ONLY Application Accepted by W. Date ✓y Area �2/ Pit or Grout Inspection by Date Final Inspection by/ IKJ fr Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 523-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 0000* I FEE INFO AMOUNT DUE AMOUNT REMITTED ;CASH CK 4 RECEIVED BY DATE PERMIT'NO. +.EH1324(REV.1/n 5) EH 14-26 /�'�