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APPLICATION.FOR PERMIT • L,J 4f SAN JOAQUIN-LOCAL HEALTH DISTRIC 1601 E. HAZELTON ON AVE., STOCKTON, CA , Telephone (209) 466-Mll PERMIT EXPIRES 1 YEAR FROM DATE ISSU.ED,.,#.�, ;E (Complete in Triplicate) ,. �,. ; ENVIRONMENtAVICES'��x PEW' 1 SEP I 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:54.9 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District: Job Address QCI� (j� �S' - [ .�ls C1-�7�/ � _ City<14Z +9 &4 Lot Size PM � PhoneOwner's Name�nftdr�if ~pddress Q&4f *0 t 1*111 qd Contractor%mkdAddress ' FId�k License No. Phonef TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ . PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Ell it'I.1A7 . DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. ;PROP.LINEY - Y FOUNDATION AGR)CULTU RE WELL "' OTHER WELL PITS/SUMPS y, INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTIONS PECIFICATIONS f� ] ❑ Industrial ❑l Open Bottom ❑ Manteca Dia. ofWell Excavation r+? Dia. of Weil Casing ❑ Domestic/Private `7lCGravel Pack ❑ Tracy Type of Casing Specifications ❑ Public !/❑'Other ❑ Delta Depth of Grout Seal ��rr) S µ Type of Grout" ❑ Irrigation V4*_ Approx. Depth ❑ Eastern Surface Seal installed by C��Nf 9CLw Repair Work Done ❑ Type of Pump _. H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 j�Or1i riA* Depth Filler Material (Below 50') ? 4 TYPE OF SE TIC WORK: NEW INSTALLATION ❑ REPAIRIADDITION ❑ DESTRUGTION ❑ INo septic system permitted if public sewer is available within 200 feet.) Installation_will serve: Residence_ Commercial Other Number ofliving units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth r SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments V i PKG. TREATMENT PLT- ❑ Method of Disposal Distance to nearest: Well Foundation Property Line (� LEACHING LINE ' ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest:- Well Foundation Property Line i M ! SEEPAGE PITS O Depth Size Number SUMPS ❑ Distance to nearest:" WeII" Foundation 'Property Line °--s:v-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. I , 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." ,. The applicant m t call for all req ui ed inspections. Complete drawing on reverse side. ` Signed X Title: Date: ' R DEPARTMENT US ONLY Application Accepts by Date � I 26 �'/ Area Pit or Grout Inspection by �m Date Final Inspection�by f /L�771 ' " Dated f Additional Comments: 1 ❑ Stk 466-6781 ❑ Lodi 359-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 t FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT-NO. INFO a EH1324 IREV-t y 51 r 1� /� r lin ,� ,a0. EH 14-28 ..J�.� �' ••