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APPLICATION FOR PERMIT (Y J SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA !e Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �! (Complete in Triplicate) Application is hereby made to the Sen,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 f r sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 43 City WLIM r Lot Size PM Owner's Name I`wlLAGGl.Q Address a'33, I Phone Contracto&-kalot r ddresst ��(J, � fJ r • License No. Phone! ! V5 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 j INTENDED USE TYPE OF,WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ? ❑ Industrial ❑ Open Bottom C1 Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack - ❑ Tracy -Type of Casing Specifications F1 Public ❑ Other Cl Delta + Depth of Grout Seal Type of Grout . I I Irrigation _""Approx. Depth I I Eastern _ Surface Seal.lnstalled by _ Repair Work Done ❑ Type of Pump H.P. State Work Done_ h Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION l I DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.! Installation will serve: Residence I Commercial Other r Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg i Capacity - No. Compartments PKG. TREATMENT PLT, ❑ I 4 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines r Total length/size— FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS [I Depth Size Number � SUMPS L� Distanc"i e 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 shalt 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: "1 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., I i� The applicant must all fora re uired inspections. Complete drawing on reverse side. Signed X Title. _ Date: Acr FOR DEPARTMENT USE ONLY Application Accepted by __ Data Area / Pit or Grout Inspection by Data _ Final Inspection byte e 0r Date 7 ( � Additional Comments: dqvi t'TJe__ ' qL $K. ❑ Stk 466-6781 D.Zod 369-3621 11 Manteca 823-7104 ❑ Tracy 835 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O."Boz 2009, Stk., CA 95201 Q ✓t- r q r,_ac J.+ 1. FEE L--c t'd- C fry INFO AMOUNT DUE AMOUNT REMITTED CK CASLH RECEIVED BY DATE PERMIT'NO. a EH 1 -241REV.1/85) �� IIAA EH 144-28 - IE