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APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 E.,.HAZELTON AVE., 5TOCKTON, CA PERMIT NO. $15'~�� Telep�nja (209) 466-,6781 DATE ISSUED 31a1 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, Job Address 1 96a Subdivisior Name Owner's Name 4o Address l 5 Phone 3� Contractor's Name G r" S �.icense No. Phone -;„— -.- - TYPE OF WELL/PUMP WORK: NEW WEL�L ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ +PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 4 i DISTANCE TO NEAREST: SEPTIC TANK - SEWER LINES DISPOSAL PLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS R Industrial r. ❑ Open Bottom ❑Manteca " Did, of Well Excavation (❑ Domestic/Private 4.• ❑ Gravel Pack ❑ Tracy .,eWla: of"Well Casing, , " .. ❑ Public ❑Other ❑Delta Type of Casing L_1 Irrigation Approx. ❑ Eastern Specifications Cathodic Protection ❑ Depth s Depth of Grout Seal �• = i ` ❑Geophysical 1 Type o,f G=rout ❑)Other �- a Y _ 4 Surface Seal installed by Repair Work Done ❑ Type df-?.,ump _ �'H.P: '� :State-lork Dane Well Destruction ❑ Well Diamet+r i = .': Sealing Material (top 50') ; Depth. Fi11er.Material (Belo' 50'} 0- TYPE OF SEPTIC WORK: NE� INSTALLATION ❑ REPAIR/ADDITION ❑ /(No septic tank or 'seepa.ge,pi.t permitted if'.public sewer i vas _ i,lable within 200 feet.) Installation will serve: Residence _ Commercial 0tho/,� umber of living units: Number of bedrooms �r Lot size ' um g Character-of soil to a;depth of 3 feet: _ Water table depth SEPTIC TANK ❑ * Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. L] Type/Mfgr Capacity - Method of 0isposalri i SEWAGE SYSTEM Distance to nearest: Well Foundations Property Line tJ'w DESTRUCTION ' 1 Total length/size LEACHING LINE ❑ No. & Length of lines _ a FILTER BED ❑ Distance to nearest: Well Foundation: Property Line SEEPAGE PITS ❑ ` Depth Size ;Number SUMPS Distance to nearest: Well Foundation' Property Line € DISPOSAL PONDS ❑ 3 ' j I hereby certify that I have prepared this application and that the work will be on in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. 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 compensationyiawsiof 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.shal'1 employ persons subject to workman's compensation laws of California." ' } The applicaq must call for all required inspections. Complete drawing on reverse side. Signed X Cf,B Title: Date: /=-2,;L y R D RTMENT US NLY ?-" Z ❑ � Area Stk 466-b781. Application Accepted by Additional ,Comments:. ❑ odi 365-3621 _ y t y Pit or Grout Inspection b Date � :. _ Manteca 823-7104 Final_IE spection`hy .,_. .. _ �, .pate- 7Y. Tracy-835-6385.. �. Applicant - Return all copies to: . Environmental Health Permit/Services 1601 F. Hazelton Ave., P.O. Box 2009, Stk., CA 45201 t FEE SASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE pµ?ERMIT{NO. INFO p� �00 51 EH 13-)� REV. 10/82 C G 5� 2 500 ir �`.