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APPLICATION FOR PERMIT ' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA JUL 13 10084 Telephone {209? 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �� ` `�F � I "� " (Complete in Triplicate) 1DBSTR MT 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 c�No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District.` Illl C Job Address � �;�t (/�Q�i - City k4A Lot Size +PM } II LPi�•ji� //��f3 d kwlR i= �f ` Phone �O Owner's Name ddress I Contractor's Name icense hl. / Phone 36 ONr-- TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR wl*� OTHER ❑ DISTANCE TO NEAREST: SEPTIC_TANKSEWER LINES DISPOSAL FLD. PROP. LINE h.--� �- FOUNDATION AGRICULTURE WELL"- f ETHER WELL-1 - '°""`-PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca bia. of Well Excavation Dia. of Well Casing LeDomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications —E] Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout �^a-13`Irrigation �pprox: Dep ❑ Eastern Surface Seal Installed by Re5 � ! ` pair Work Done GX Type of Punilp State Work Done,« � n C Well Destruction ❑ Well Diameter Sealing Material (tap 50') Depth I Filler Materrial (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is I! available within 200 feet"i Installation,will serve: Residence y� Commercial_ Other ` —N,Mber.,of living units:' Number,of.bedrooms r. -- -•- -- ' ;, 'vF I Character of soil to a depth of 3 feet Water table dept-` SEPTIC TANK ❑ Type/Mfg I Capacity No. Compartments PKG. TREATMENT PLT. ❑ I� r Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines "' f! Total length/size FILTER BED ❑ Distance'hto nearest: Well # Foundation=- Property Line SEEPAGE PITS ❑ Depth j` Size Number SUMPS ❑ Distance to nearest: Well I Foundation Property Line DISPOSAL PONDS ❑ I 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:,_"./-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 i 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 t ca for all ired"inspections. mplete drawing'on reverse side. Signed �M !�'Ritle: Date: I /�. / FOR D ARTMENT USE ONLY Application Accepted by v I� Date-- _ _9? Area Pit or Grout Inspection by 'I Date Final Inspection by Date G Additional Comments: I� ❑ Stk 4666761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 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_ CK# RECEIVED BY DATE PERMIT'NO. INFO CASH 11) //� ry` ']a + EH 1}24(REV.10/83) 45 �I R�� !4/ + .-� (iv I EH 1426