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APPLICATION FOR PERMIT �. SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL i ON AVE., STOCKTON, CA Telephone (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 well/pump and the Rules and Regulations of the San Joaquin Local Health District.., - l�/ �j all rwex. e u�7 � fffO f , / Q�X 275 PM Job Address [ City Lot Size C1�i Z�1. �1ZlJ Address ��• �a Phone p Owner's Name b Contractor Address zJ� ILA��19 .License No. d��3 Phone TYPE OF WELL/PUMP: V NEW WELL 9 WELL REPLACEMENT ❑ gDESTRUCTION! ❑. PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑` t DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES_ DISPOSAL FLD._/OD 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 �i Domestic/Private X Gravel Pack X Tracy Type of Casingi Specifications (� ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Z[)j} Type of Gr ut x ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by r Repair Work-Done—El- Type of Pump H.P. State Work Done Well'.Destruction E) Well Diameter *t'Sealing Material (top 50') s y } Depth Filler Material (Bellow 501 E OF SEPTIC WORK:--NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation wi e: Residence_ Commercia�_ O�ther Number of living units: Number of bedroom ! Character of soil to a depth of 3 fe Water table depth SEPTIC TANK ❑ Type/Mfg, Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well �ynd�,tio, Property Line3 A LEACHING LINE ❑ No. & Length of Anes I lengthlsize FILTER BED . ❑ Distance to nearest:' Well r Foundation Line SEEPAGE PITS ❑ Depth Size Number I SUMPS ❑ Distance to nearest: Well ' Foundation Property Line 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 District. ( t II 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 folrowing: "1 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 st call for ail required ." pections. Cam ate drawing on reverse s" ,. Signed Title. Date: Z OR DEPA MENT USE ONLY f ,u�f� " Application Accepted by Date 1 o !Area Pit or Grout Inspection by Date I l Final Inspection by Date ; Additional Comments: ` ❑ Stk 466-6781 ❑ Lodi 369-3521 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO cm + EH 13-24IREV.I/95} - - EH 14-26 • coo 17-9 ��-1�q