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— .- � 7-0Y o 11 9 fJD� APPLICATION FOR PERMIT Al en SAN JOAQUIN,LOCAL HEALTH DISTRICT { 1601 E. HAZE i ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1,YEAR FROM DATE ISSUED u. V (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 $ I Local Health Di n 7 f(� 12 7C Job'Address i Phon33 e Owner's Name Address —c, License No. Contractor's Name Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT 1.3DESTRUCTION 11 k PUMP INSTALLATION Zl---' SYSTEM REPAIR ❑ OTHER ❑ P l DISTANCE TO NEAREST:'SEPTIC TANK SEWER LINES — OTHER WELLD� PROP: LINE FOUNDATION — AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL ' 'PROBLEM AREA CONSTRUCTION SPECIFICATIONS l� ❑ Industrialn Bottom [5 Manteca Dia, of Well Excavation Dia. of Well Casing Type of Casing *� Specifications l omestic/Private ❑ Gravel Pack ❑ Tracy 9 ❑ Other ❑ Delta Depth of Grout Seal d Type-of Grout El j ,,, El Irrigation ---Approx. Depth 11stern 'Surface Seal Installed by Repair Work Done.r❑ Type-of Pump H.P.' State Work Done Well Destruction ❑ Well Diameter Sealing Materia! (top 50') Depth ' Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIADDITION ❑ DESTRUCTION ❑ al o septicable systemithin .r ti}ed if public sewer is Installation will serve: Residence— Commercial— Other '- Number oflivingunits:. Number of bedrooms Character of soil to a depth of'3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments --v ' Method of Disposal PKG.TREATMENT PLT. F1. Distance to nearest:.- Well Foundation Property Line LEACHING LINE ❑ No. & Length oflines- Total length/size ' FILTER BED ❑ Distance to nearest: Well Foundation K Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑_ ordance with San Joaquin county ordinances, state laws, and hereby certify that.1 have prepared this application and that the work:will be done in acc 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, l 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.ho plate drawing on reverse side. Signed Title: .i,. Date: C FOR DEPARTMENT.USE ONLY r, r: fw Ara e _. Q Application Accepted by Date - a Date i�F.� P Pit or Grout inspect' n Date 023 P Final Inspection by Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3821 ❑ Manteca 823-7104L ❑ Tracy 835-6385 l Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 Applicant- Return all copies to: Environmental Health " FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. 4� INFO' + EH 13-24{REV.10/83} `C/�J / ? y �(/J ✓ 06 I Ek 14.26] .