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�►^-�—� a APPLICATION FOR PERMIT ! h L :S Oc,, S SAN JOAQUIN LOCAL HEALTH DISTRICT-I-\ 1601 E. HAZEr_T ON AVE., STOCKTON, CA ~� � Telephone {209} 466-6781 IA 5 P. 61 PERMIT EXPIRES 1 .YEAR FROM DATE ISSUED (Complete in Triplicate) D r 1V 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 City of Size )'(0 PM t Owner's Name--Z ,1N/• 1l. IIS Address 301. MPhone F Contractor's Name License No. 3722 © V0 Phone )` TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 9 DESTRUCTION PUMP INSTALLATION ❑e SYSTEM REPf1IR X OTPER ❑ v DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES O ISPOSAL FLD/_00 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 X Domestic/Private ❑ Gravel Pack F-1TracyType of Casing 3�e Specifications � ❑ Public Other ❑ Delta Depth of Grout Seal -5-04 Type of Grout �`} 60 7— ❑ Irrigation npprox. Depth Eastern Surface Seal Installed by n , Repair Work Done Type of Pump H.P. State Work Done Well Destruction Well Diameter Sealing Material (top 50') !� Depth�.� Filler Material (Below 501 _ LcL TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No 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 I SEPTIC TANK El- Type/Mfg _ Capacity No, Compartments PKG. TREATMENT-P.LT;❑:_ # n Method of Disposal Distance to nearest:., Well ' Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size 1 FILTER BED ❑ Distance to nearest: Well Foundation Property Line ` z i SEEPAGE PITS ❑ DepthSize ` Number SUMPS LJ -Distance to nearest: . Well Foundation Property Line DISPOSAL`PONDS ❑ 4 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- rulesL hd regulations of the San Joaquin Local Health District.;,LWx '•tl 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, 1 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 tri the performa a of a work for which this permit is,lssued_,I shall employ persons subject to workman's compensa- tion laws of California.'; r t The applicant c fot all re�quir pe ions. �plete drawing on reverse side. y � Signed cTitle: Date: a'��_ FOR DEPARTMENT USE ONLNY r"t Applic ion Accepted by Date_ dIle Area Pit or Grout Inspection by Date Final Inspection by S Date`l Additional Comments: . ❑ Stk,466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 --0- C'_Tracy 835-6385" ; Applicant- Return all copies to:.Environmentai_Health Permit/Services"1601,E.'Hazelton Ave�P.O/Box 2009, Stk., CA 95201 FEE INFO AMOUNT-OUE-T AMOUNT REMITTED CASH CK 11 RECEIVED BY DATE PERMIT`NO.p +EH 13-24(REV.10/83) 1 g, S I EH 1426 �� G 4 Vic. •.