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I I i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL—ION AVE., STOCKTON, CA Telephone (209) 466_6781 PERMIT EXPIRES-1 YEAR FROM DATE ISSUED (Complete in Triplicate) 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.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address /✓�� '/ r: eT' City T3Ad Y Lot Size PM .Owner's Name.. iP` T �O� E_ _ Address-- 9 - - - Phone -- w Contractor G• A' jlOH ze Address 1 0 �Q.r /f� License No.��T v ✓ Phone ;TYPE OF WELL/PUMP: j NEW WELL ❑ " WELL REPLACEMENT ❑ DESTRUCTION ❑ ' PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ .,.,OTHER ❑ i VDISTANCE TO NEAREST: SEPTIC TANK SEWER,LINES�: ' `� DISPOSAL FLD. PROP. LINE FOUNDATION71 ` AGRICULTURE WELL OTHER WELL PITS/SUMPS 'i INTENDED USE., TYPEOF-WELL . PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open_Bottomi fill Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ; ❑ Delta Depth of Grout Seal Type of Grout ~ ❑ Irrigation Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Dane Well Destruction ❑ Well Diameter t- - —Sealing-Material-/fop-50'i - Depth el" Filler Material {Below 501 I TYPE OF SEPTIC WORK: NEW INSTALLATION')f REPAIR/ADDITION DESTRUCTIO (No septic system permitted if public sewer is s - available within 200 feet.) ' Installation will serve: Residence��=Commercial Other ! Number of living units: Number of bedrooms ly f Character of soil to a depth of 3 feet: VWy "Ase a Water table depth SEPTIC TANK ❑ Type/Mfg ' fes` _ Capacity i!f No. Compartments PKG. TREATMENT PLT. ❑ �„rost Method of Disposal Distance to nearest: Well ^ CO /D Foundation Property Lines LEACHING LiNE No. & Length of linesTotal length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line �-r� .i, i SEEPAGE PiTS ❑ Depth '$ize- _ Number SUMPS D Distance to nearest.IN Well 64. Foundation .x"�` Property Line DISPOSAL PONDS ❑ 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state land rules and regulations of the Sart Joaquin Local Health,District. 4 aws, 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 became subject to workman's compensation taws 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." f ' I The applicant must ill for all required inspections. Complete drawing on reverse side., Signed g Titley Date: x FOR DEPARTMENT USE ONLY y-� A _` 1 Application Accepted by Date �L - Area � £ •. Pit'or Grout Inspection by � _ Date Final-Inspection by Additional Comments: , ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104-. 0 Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 16U1-f.,Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE CASH PERMIT NO. + EH1&24(REV.i/a5) 041-) � y 4. EH 1429 �S�t