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APPLICATION FOR PERMIT w s SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEJON AVE„ STOCKTON, CA Telephone (209) 466-6781. PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) Application is.heteby,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$Jn g6in'Counfy.Ordihanca�No. 54946r.sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health,.Disinci I; A �a E s, Y s- rf Job Address c City Lot Size PM Owner's Name � ��- Address 23 9 Phone G- 7;R Conlraclor . &t./ Address �d Glx f. 0 icense No. 2�/r�� Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT X DESTRUCTION-0 PUMP INSTALLATIO��N��❑� SYSTEM .REPAIR ❑ ��OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK (0 SEWER LINES DISPOSAL FLD. f"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 'Domestic/Private X Gravel Pack X Tracy Type of Casing 16 VIC, Specifications ri Public n Other 71 Delta Depth of Grout Seal f _ Type of Grout I I Irrigation --Approx. Depth I I Eastern Surface Seal Installed by 1 r1f 1J. ij�, Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') r `` TYPE OF SEPTIC WORK: NEW INSTALLATION I'] REPAIR/ADDITION 13 DESTRUCTION l I (No septic system permitted if public sewer is W available within 200 feet.) Installation will serve: Residence_ Commercial_ Other 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 44&MY top Z LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance.tD nearest: Well Foundation Property Line MAP '3 1989 SEEPAGE PITS i I Depth Size Number rnr.r RIGNnzEN L HEALTH SUMPS LI Distance to nearest: Well Foundation Property Line PERW 1 SERVICES 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." Contractors hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which his permit is issued, I shall employ persons subject to workman's compensa- tion laws of C ifornia." The appii ant ust call for all re red inspections.�omplete drawing n ver a side. Signed X ' Title: Date: 15,-1 (L�.-.M FOR EP TMENT USE ONLY j. Application Accepted by Date 3��__ Area d V/, s- Pit or Grout Inspection byDate Final Inspection by 1 Date Additional Comments: Y C3 kMdih^ t g� ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 INFO AMOUNT DUE AMOUNT REMITTED CK 0 H RECEIVED BY DATE PERMIY'NO. +,EH 13-24 IREV. /x 51 EH 14-29 ��—� /fP ��