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APPLICATION FOR PERMIT � �M r 11 SAN JOAQUIN LOCAL HEALTH DISTRICT � � U 1601 E. HAZEL T ON AVE., STOCKTON, CA DEC 3 19 � Telephone {209} 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED EN 1jR N1` ;� '�f`�SEW��1LA`Tri {Complete.in Triplicate} PERMIT 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 welllpump and the Rules and Regulations of the San Joaquin Local Health Distri�ttt. �] Q � & A Job Address _(ZL—pj F City Lot Size PM '1 Owner's Name Address C+ Phone p q / Contractor Addres )cense No. 1 9 hone_ TYPE OF WELLCPUNEW WELL ❑ 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—i_,,:.: INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia.,of Well Excavation Dia. of Well Casing 3�16omestic/Private d Gravel Pack ❑ Tracy Type of Casing Specifications M Public F1 Other Ll Delta Depth of Grout Seal Type of Grout I I Irrigation __.Approx. Depth i I Eastern Surface Seal Installed by 0-1 Repair Work Done Type of Pump .dare H.P. � State Work Don Well Destruction ❑ Well Diameter Sealing Material atop 501 Depth Filler Material {Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 11 RFPAIR/ADDITION LI DESTRUCTION I 1 iNo 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 ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property.Line LEACHING LINE ❑ No. & Length of tines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line _ DISPOSAL PONDS ❑ ti a, . Q6 1 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. Horne 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 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 mustc for all required inspections. Complete drawing on reverse side. Signed X Title: S��l i^t c i e.,221A-7, Date: 152-9 FOR DEPARTMENT USE ONLY Application Accepted by / I Date ` r Area r Pit or Grout Inspection by ate nal Inspection by Date �f Additional Comments: ❑ Stk 466-6781 Ladi 369 3621 Men ca 823-7104 ❑ Tracy 835-6385 x Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave„ P.Q. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'NO. +.EH 18-24(REV.It N 5) r I=_H 14-28 l 9