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APPLICATION FOR PERMIT SAN JOAO.UIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 / I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED •"� �� j'� �' (Complete in Triplicate) ., 4 � .w Application is her made to the San; .oaquin 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 Ryles and Regulations of the San Joaquin Local Health District. �( Jab Address f City Lot Size PM /1 Owner's Name Contractor' S Gl - / one O } d ess Q License No. Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ f 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 ❑ ndustrial ❑ Open Bottom E5 Manteca Dia. of Well Excavation a Dia. of Well Casing 1 7�piA omestic/Private ' t ❑ Gravel Pack ❑ Tracy Type of Casing Specifications /❑"Public f t ❑ Other �• ❑ Delta Depth of Grout Seal Type of Grout AIrrigation _ ---Approx. Depth astern Waco Seal Installed by /Repair Work Done ❑ Type of Pump H.P. St AWork Done i Material 50')Well Destruction 1-1Sealin, Well Diamet r/ g oto P Depth Filler Material (Below 50'I TYPE OF SEPTIC WORK: NEW INSTALLATION 1:1REPAIR/ADDITION EDDESTRUCTION ❑ (No septic system permitted if public sewer is ` available within 204 feet.) Installation will serve: Residence— Commercial�_ Other ti Number of living units: -- Number of bedrooms Character of soil to a depth of+3 feet. f Water table depth SEPTIC TANK ❑ TypeiMfg Capacity No. Compartments PKG. TREATMENT PLT. Clf f '. Method of Disposal a Distance to nearest: Well_ .� Foundation Property Line LEACHING LINE _} ❑ No. & Length of lines Total length/size FILTER BED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS 6 ❑ Depth- Size ` Number l SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ !� f 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 ' I 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." The applicant must call for all required inspections. Complete drawing on reverse side. XSigned Con= Title: LADate: FOR DEPARTMENT USE ONLY /0. Application Accepted by 6141 Date Area i Pit or Grout Inspection by ""' ; bate Final Inspection by Date Additional Comments: s ❑ 5tk 466-6781 C1Lodi 369-3621 E:1Manteca 823-7104 LI'Tracy 835-6385 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 CASH RECEIVED BY DATE: PERMIT'NO. INFO +.EH 13-24{REV.t/a 5) ✓ +�F �Q 115 � . EH 14-26