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APPLICATION FOR PERMIT S "�j �'�� • SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA i')Arf �Y Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) f��_/� DEC Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install thwOrk cribed. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the WTI qf, ^B San Joaquin Local Health District. pVic, Job Address 2 • C pN r �q' o � City Lot Size PM Owner's Name 1`r4f• t � +t`G ��0.4`- Address A15 4&WP— Phone 4 Contractor Address License No. 5 TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER _ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE I_Sot FOUNDATION AGRICULTURE WELL OTHER W-LL - _ PITS/SUMPS _. 1 -10 t INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS [7, Industrial of Well Casing Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 9 ❑ l3omesticlPrivate El Gravel Pack C1 Tracy Type of Casing �o r Specifications k�olep� I'1 Public Cl Other F.1 Delta Depth of Grout.Seal !D /—�5a Type of Grout�t•7._Lk _-_- 1 I Irrigation --Approx. Depth I i Eastern Surface Seai Installed by 1 - Repair Work Done ❑ Type of Pump H.P. State Work Done _ I Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') — TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION t I DESTRUCTION I 1 (No septic system permitted if public sewer is , available within 200 feet.) i J Installation will serve: Residence_ Commercial— Other 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. Compartments PKG. TREATMENT PLT- ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size 73 FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I Depth Size Number SUMPS I_1 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 DFstrict. if that in the performance of the work for which this permit is issued, I shall not following: "l cert If. certifies the fo Y I Home owner or licensed agent's signature g employ any person in such manner as to become subject to workman's compensation laws of California."Contractors 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 applica st call for all r9quired inspections. Complete drawing on reverse side. Signed X Title: . Date: OR DEPARTMENT USE: ONLY �� Application Accepted by Date ��...—fv Area Pit or Grout Inspection by — Data Final Inspection by Date Additional Comments: - 0 Stk 466-6781 ❑ Lodi 369-3621 ❑ MarkWai& 823.7104 ❑ Trac 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave.,`P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. INFO ?_,40 L7 a] 96-53 I' + EH 1324(FIM+I R 51 l�