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1 `J APPLICATION FOR PERMIT t� ►/ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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 Ryles and Regulations of the San Joaquin Local Health District. Job Address City Lot Size PM Owner's Name Oh� SO ti i3SO Q Address A 1Q 1 e_6 S Phone L � d 16 ontractor p.14.P40-41 s;6 tso&ddress .3f92W CA-),"e-5 ar) 5-13 icense No. 6� Phone t TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r /) ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing V ❑ Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Dalt' Depth of Grout Seal Type of Grout ❑ Irrigation —Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Bel 1501 TYPE OF-SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ;DESTRUCTION No septic system permitted if public sewer is available within 200 feet.) Installation will serve: ResidenC Commercial_ Other Number of living units: 'Num of bedrooms Character of soil to a pth of 3 feet: Water table depth SEPTIC TANKTygpe/MfCapacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to,nearest: ` Well Foundation Property Line a LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number s SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that 1 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. 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 sur ect to workman's compensation laws of California."Contragt hiring or sub-contracting signature certifies the following:"I certify that in the-performance of the work for which thispermit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicantm II for all re u' ins ti s. Complete drawing'an reverse s e. .y r Signed X Title fit �_ \JLC Date: s� FOR DEPARTMENT USE ONLY .� Application Accepted by Date ' if-7 Area p Pit or Grout Inspection by // Date Final Inspection by Date Additional Comments: k- — t 17, pl7::ff ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 If Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK CAH RECEIVED BY DATE PERMIT"N0. + EH 1 -24(REV.1/85) %;S�OC� EH 144-28 ✓•+ $