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'i 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 hereby made to the SanJoaquinLocal 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. /T�C�} !/dl�c%:� /[-� i dn.�PCrf Lo Size 1��1•CJ�' PM J�� Address 7r` �♦ Cit. t 5 e.�. Owner's Name '�+ � �` Address fii� &84atni� U_- Phone Ca. Contractor ��' (' Address Q.S tO4d,- License No. Phone .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 3 I!a`Uomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F'3 Public 171 Other11 Fl Delta Depth of Grout Seal Type of Grout _ I ! Irrigation —.Approx. Depth// I I E �tern J/ Surface Seal Installed by _ g l� Repair Work Done ❑ Type of Pump s�a4M�e+�lra�/✓ H.P. � State Work Don Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth 1 Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION is REPAIR/ADDITION LI DESTRUCTION I I fNo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial— Other Number of living units: Numberofbedrooms Character of soil to a depth of 3 feetWater table depth e SEPTIC TANK ❑ Type/Mfg C Ity No. Compartments PKG. TREATMENT PLT. ❑ .t Method of Disposal Distance'to nearest: Well Foundation Property Line LEACHING LINE ❑ Na. & Le9 gth o es Total length/size FILTER BED ElDistanc nearest: Well Foundation Property Line SEEPAGE PITS i l Depth J Size Number SUMPS ❑ 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, 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, 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." 1 The applicant must call for al equir97 inspections. Complete drawing on reveese side. , Signed Title: tom�-.+_�� ._ Date: _ .I. ,�A FOR DEPARTMENT USE ONLY Application Accepted by U� .U1�j�1 Date G Area 4 Pit or Grout Inspection Date Final Inspection bye Date Additional Comments: ❑ Stk 466-.6781 ❑ Lodi 369-3621 E 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 FEE INFO AMOUNT DUE, AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. + EH 13-24(REV,1/8 s) in gEH14-28 J tJ `C b S F"'i ?s