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f T 5 w- APPLICATION FOR PERMIT r t SAN .fOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON ON AVE., STOCKTON, CA Telephone 1209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I` (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. ]862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. ° Job Address Co City r5tm Lot Size PM Owner's Name AAA)- Address R "' �5 Phone C� Conlractor�� L' � HC'J 7{ Address Lim enie^Noi.w f� Phone TYPE OF WELL/PUMP: NEW WELL D WELL REPLACEM6W-_-8--------_DES:PR!Ic 1 _ _ - ---- E PU.MP INSTALLATIQN ❑ W SYSTEM REPAIR ❑ OTHER ❑� DISTANCE TO NEAREST: SEPTIC�TA�IV,K-�� 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 E] Manteca Dia- of Well Excavation Dia. of Well Casing. i D Domestic/Private �D Gravel Pack © Tracy Type of Casing r r �� Specifications [ M Public n Other fl Delta Depth of Grout'Seals� - 'i� I-_ Type of Grout t• . J�I t _ ii I ! Irrigation �_.-Approx. Depth I I Eastern Surface Seal InstalleA' `-f" `-__E: - r ' Repair Work Done/0 Type of Pump H.P. State Work Done = V'6 Well Destruction/ l y,=n ',Weil Diameter Sealing Material,ltop 50'f ; 'z i �7 'Depth I ` � Filler Material Ieelowf� �f -� —+jjrf � TYPE OF SEPTIC WORK: [NEW INSTALLATION 1] REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if publjc'e.Wef is y" t available within 200 feet.)l I Installation will serve: Residence ! Commercial— Other Number of living,dennits: i Number of bedrooms Character of'soil t`o a depth of 3 feet: Water table depth ++ r - -- SEPTIC TANK � ❑. Type/Mfg Capacity No. Compartments? s PKG. TREATMEN41-T. Ot I Method of Disposal f Distance to nearest: Well Foundation Property Line r l LEACHING LINE ❑ No. & Length of lines Total length/size i FILTER BED © [ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I Depth Size _ Number SUMPS Cl ',Distance to nearest: Well Foundation Property Line [ DISPOSAL PONDS D [ I hereby certify' that I have prepared this aapplication_and-that-the-work-will-be'd6ne in' a—ordance-with-San Joaquin-countyjordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agents 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." i The applican require omplete drawing onpa rave side. t Signed r itie: ~' Date: FOR R DEPARTMENT U E ONLY Application Accepted by rn Date Arae Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Silk 466-6781 © Lodi 369-3621 CI 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 i 1 FEE CK 41 INFO AMOUNT DUE! AMOUNT REMITTED CASH RECEIVED BY ^{' DATEE(}[�� (��(PPEERMITNO. M ♦.EH 1324 1 REV.I/H 5742 t7 l EH 14-26 E