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APPLICATION-FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephohe (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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. 1862 for welUpump and the Rules and Regulations of the San Joaquin Local Health District. Job Address ID i Q City 11/1'll.ot Size 22-A - PM c et b1of 0"o D�6Z PWI-. - Owner's Name �� ,� Address !�,u `Wk-tPhone S` I Con actor Address 770 J^ a Le G" d7l License No.3R/59�V Phone TYPE OF WELL/PUM : NEW WELL�< WELL REPLACEMENT ❑ DESTRUCTION ❑ i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ { DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL _ OTHER WELL PITSISUMPS r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Z� ❑ Industrial Open Bottom 11 Manteca Dia. of Well Excavation Dia. of Well Casing t ❑ Domestic/Private C1 Gravel Pack ❑ Tracy Type of Casing Specifications z o r 11 Public fl Other ❑ Delta Depth of Grout Seal r Type of Grout r ligation ____-Approx. Depth I I Eastern Surface Seal Installed by r" _ ` Repair Work Done ❑ Type of Pump H State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 f Depth Filler Material (Below 501 ',TYPE OF SEPTIC WORK: NEW INSTALLATION I I fIEPAIR/ADDITION i I DESTRUCTION l 1 (No septic system permitted if public sewer is a available within 200 feet-) Ir Installation will serve: Residence_ Commercial— Other /tel Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth I SEPTIC TANK 1 '� ❑ Type/Mfg Capacity No. Compartments 1 s PKG, TREATMENT PLT.❑1 f; Method of Disposal t Distance to nearest: Well Foundation Property.Line e t LEACHING LINES ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line 1 i SEEPAGE PITS l 1 Depth, Size Number �} SUMPS ❑ Distance to ne t: Well Foundation Property Line I ! DISPOSAL.PONDS ❑ 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 Di§trict. 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 signatur 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 mu uiced ins ctions. drawing on reverse side. q,py Signeditle: � Date: I !O r � FOR DEPARTMENT USE ONLY ? Application Accepted by a & M k � � Date _U'_16 s Area Pit or Grout Inspection by Date Final Inspection by �LdDate i Additional Comments: ❑ Stk' 466-6781 ❑ L i 1 ❑ 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 4 CASH RECEIVED 8Y DATE PERMIT'NO. " INFO ♦.EH-fW4,IREV.1/XN 5) o ��,� "�� / g V'f• / EH 1� I YY V