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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. Job Address / City Lot Size YO &&5 PM Owner's Name Address /Q� 7 11 Crf r Phone -356 Contractor Uoa&A Address 1124 License No.i:26,061 Phone_ 3 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f'l Public Cl Other C-1 Delta Depth of Grout Seal Type of Grout I I Irrigation y Approx. Depth l 1 Eastern Surf ce Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. 1 ewe� �-- State Work Done �ff 4,asp Well Destruction ❑ Well Diameter Sealing Material [top 50'1 Depth— / Y1_2 Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION {1 REPAIR/ADDITION 1 1 DESTRUCTION I 1 INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial— Other C� Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth C. SEPTIC TANK ❑ Type/Mfg Capacity NO a x� iP t 1"I I n j o a V PKG. TREATMENT PLT. ❑ Met i s Distance to nearest: Well Foundation Property fine 1 LEACHING LINE 0 No. & Length of fines Total length/size U L ry 0I FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I Depth Size Number �cQ{/1Z1SFf?VI(`F� SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL 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, andk" 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 folio ' g: "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 Calif ria." The applica t call for all requir inspectio Co lets drawing on reverse side. Signed X_k Title: Date: Fgfi DEP rfUlE USE ONLY Application Accepted byDate – ;- Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 L FEEINFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY ` CATE PER•MIT'NO. +.EH13-241REV.iix5Y CIL�^ EH 1426 ~.�'L I