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APPLICATION FOR PERMIT SAN JOAQUIN 'LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is he+eby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is + madH 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 d ' /� r s - City Zo In Lot Size 36&A2 PM r U Owner's Name Address5. • - Phone Contractor 1 a. I Address License No. Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION LJ PUMP INSTALLATION" SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK, / SEWER LINES DISPOSAL FLD. PROP. LINE ,' A_ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 160 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ,I f ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private �[Gravel Pack ❑ Tracy Type of Casing_ p4C Specifications 4 y / e / �I'i Public ❑ Other n Delta Depth of Grout Seal ss Type of Grout 1 1 Irrigation o,7�AppFox, Depth 1 1 Eastern Surface Seal Installed by. Repair Work Done ❑ Type of Pump �ff�f r� H.P. / r State Work Done ,�i Well Destruction ❑ Well Diameter'1 Sealing Material (top 50') Depth ��jil z Filter Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION I i DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.1 Installation will serve: Residence_.Commercial_ Other q Number of living units: Number of bedrooms Character of sail to a depth of 3 feet: '1 Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments 'V PKG. TREATMENT PLT. ❑ ' Method of Disposal Distance to nearest: Well Foundation Property Line 1 , LEACHING LINE ❑ No. & Length of lines Total length/size r FILTER BED ❑ Distance to inearest: Well Foundation Property Line SEEPAGE PITS 1 I Depth Size Number w SUMP'S 'ff�Distance toa res—v W&II —Foundation �proparty Cin-eqan DISPOSAL PONDS F1I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state l rules and regulations of the San Joaquin Local Health Di§trict. v 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 full erg:"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 Ca f nia." i The applica tt call for all req&,, d,,instpecn_sCompIete drawing on re rse sie.Signed XTitle: Date: `� hNN I DEPARTME T USE ONLY r Application Accepted by Date t Area »> _ Final Inspection YZ OPit or Grout Inspection by Data V0. ` AIG,-, Additional Comments: n..f-� ..✓.,� c�� 'r�Pc,e.-�:-.� C�tp� .._.,d�;,.h�,..� �1� i-v �� tiL,p� c.-4 ac.twf- C3SeE4-A4; ❑ Silk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 839-&M5 J Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 20OC!S1k., CA 95201 .4 . N4 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY (DATE PERMIT'NO. INFO CASH *.EH13-24(REV.i i n s) 16 r