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APPLICATION FOR PERMIT � n� t SAN JOAQUIN LOCAL HEALTH DISTRICT P� 1601 E. HAZELTON AVE., STOCKTON, CA ��8g Telephone (209) 466-6781 pPR 1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I ft;IZgL (Complete in Triplicate) nQlAll E�.VIRC ��l� 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 j made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for welUpump and the Rules and Regulations of the San Joaquin Local HeCh District. t Job Address 1, ! Q A i�t•-y�! Lot Size PM Owner's Name Q.�IJ��3^ l Address _J ©• � / (G ALL Owner - Phone Contractor Address ice nse No. -7A9 1 Phone 6IS- Q TYPE OF WELL./PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK /207te.. SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUNEYS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r1 Jr ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private )(Gravel Pack _X Tracy Type of Casing + �� Specifications M Public ❑ Other Cl Delta Depth of Grout Seat - - - Type of Grout Irrigation _Approx. Depth I I Eastern Surface Seal Installed by � Repair Work Done ❑ Type of Pump H.P. State Work Done _ I Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION l I DESTRUCTION I 1 iNo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial— Other 4� 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 lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS it Depth Size Number - SUMPS [:I - Distance to nearest: Well Foundation� Property-Line DISPOSAL PONDS ❑ 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 Diltrict. 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 become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the full wing: "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 C _torn The applican ust call for.all requ' inspections. Co lets drawing n ever de. ' Signed X t Title: Date: OR [,TEPA MENT USE ONLY Application Accepted by Date �r .` Area Pit or Grout Inspection by Date Final inspection by �Date a /d Additional Comments: A-,.2,2 ❑ Stk 466-6781 ❑ Lodi -3 ❑ Manteca 3-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY y, DATE PERMIT"NO. +.EH 14-24 iREV.1/H 51 EH 14-28 111 Il