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APPLICATION FOR PERMITSe SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE:.TON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIIAES 1 YEAR FROM DATE ISSUED a.•JCornplete in Triplicate! K 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 I made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for weil/pump and the Rules and Regulations of the San Joaquin Local Health District. r u 4 # Joh Address G 50 S, Ce26L t f A G 1y/:� �/y� +f�J1 s 4 }nt City~S�Cx.��Lot Size� PM x1'ti r2S M ! L D F.� Address 3. •Phone 22 .. Owner's Name ,. a ContractorMIhE �L4hL6I Address cerise 5•�,C�4 �..! FJ��icense`"No`� Phone ___1 TYPE OF WELL/PUMP: NEW WELL D }r WELL REPLACEMENT" ❑ DESTRUCTION 171 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ M OTHER D DISTANCE TO NEAREST: SEPTIC TANK r SEWER LINESDISPOSAL FLD. PROP. LINE .i FOUNDATION AGRICULTURE WELL OTHER WELL -PITS/SUMPS ._ INTENDED USE TYPE OF WELL PROBLEMVAREA CONSTRUCTION SPECIFICATIONS ` a ❑ Industrial ❑ Open Bottom ❑ Manteca l Dia`"of}}Well Excavation Dia. of Well Casing d Domestic/Private D Gravel Pack C3 Tracy Type df Casing Specifications C7 Public 'EJ Other �"-D Deltas""" "' `'"'DepthlIf Grout Seal y"" "" Type of Grout ❑ Irrigation ---Approx. Depth D Eastern Surface Seal Installed by I j Repair Work Done ❑ Type of Pump H.P. State Work Done I Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Belo 501 I TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ lNo septic system permitted if public sewer is available within 200 feet.) 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 ` SEPTIC TANK D Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ �`' Method of Disposal l Distance to nearest: Well Foundation Property Line LEACHING'LINE ❑ No. & Length of lines Total length/size s FILTER BED ❑ „Distance to nearest: Well Foundation Property Line C; SEEPAGE PITS ED Depth Size Number l SUMPS LJ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS E3I 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 i 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 muFt all for required inspeckigns. Complete drawing on reverse side. . . . ' Signed ' " Title: _ . T: Date: J~C4 � 7 FOR DEPARTMENT�USE ONLY " Application Accepted by Date Area pr(� Pit or Grout Inspection by Date Final InspeVon y 1 11 C� Date Q J Additional Comments: S .^1 ❑ Stk 466-6781 ❑ Lodi 369-3621 D Manteca 89-71 ❑ Tra4 835-6385 Applicant'- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2D09, Stk., CA 95201 FEE AMOUNT.DUE AMOUNT REMITTED SH RECEIVED BY DATE PERMIT NO. INFO + EH 13.241REV.s/95l EH 1428