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i � T APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone {209} 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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 Local Health District. Job Address F. 3 SO- 8twrrsj . Ems]ovf City"__...-Trc,0ir Lot Size PM Owner's Name . Su7li..VnY0. Address. F;al a Phone Contractor's Name Doug 11 License No. 364:92.1Phone 83 6-2 787 TYPE OF WELL/PUMP: NEW WELL EX 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 ' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION.SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 'F 75 Domestic/Private Gravel Pack Tracy Type of Casin pvc. 6 Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal rly Type of Grout + ❑ Irrigation ---Approx. Depth t❑ Eastern Surface Seal Installed by Others Repair Work Done ❑ Type of Pump H.P. State Work Done ` Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is s `"I 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:_ "x Water table depth SEPTIC TANK ❑ Type/Mfg , Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal r +j Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED F - ,� ❑ Distance to nearest: Well . as� .Foundation Property Line SEEPAGE PITS ❑ Depth ! Size a Number -SUMPS ,❑ A Distance'Ito 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. j Home owner or licensed agent's signature certifies the following: 1 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." 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 applicant must call for all re d i spections. Complete drawing on reverse side. Signed s / Title: — O � C�B$ Date: �_ y8�r F R DEPARTMENT USE ONLY Application Accepted by H khp Date m� T Area + Pit or Grout Inspection by Date OV� Final InTwrzw-v tion by Additional Comments: 0 !� B /Lf+[I I4i► // ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 EfTracy OFW6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEEINFO �A+M�7O�}UNT DUE AMOUNT REMITTED CK 0 CASH RECEIVED BY + DATE PERMIT'NO. + EH 13-24(REV. 10/83) !6 /{ it-a'3-� 8'5-13q7 IHI428