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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT t 1601 E. HAZELTON-AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ' �r ., {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 an Joaquin Local Health District. r o f Job Address C'r NLot Size PM U Name ame U N Address u• Phone - l L! � V V� Contractor's Name 0iLicense No. `9 b Phone �u 7r✓v 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 t FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE:OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI NS 4e r v ❑ Industrial ❑ Open Bottom _❑ Manteca Dia. of Well Excavation a Dia. of Well Casing I IKQbmestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing-4 Specifications ❑ P}Iblic Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Nigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. �-- _ State Work Done ` Well!Destruction ❑ Well Diameter Sealing Material Itop 50') l Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is r available within 200 feet.) nitallation will serve: Residence— Commercial_ Other —� 7_N mber of living units: Number of bedrooms �.G�aracter of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments f P:KG! TREATMENT PLT. ❑ . Method of Disposal Distance to nearest: -Well' Foundation I Property Line J _._ m EEA9HING LINE ❑ No. & Length of lines j r Total length/size �- FILTER BED ❑ Distance to nearest: WellFoundation.. Property Line 1 .SEEPAGE PITS ❑ Depth Size j • va Number I" !F f s `SU PS ❑ Distance to nearest: Well Foundation PropertyLinei DIS OSAL PONDS ❑ i € 'I'6er�by certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and ,rule"and regulations of the San Joaquin Local Health District. Hoe 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 emp ay 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 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.aws of California." x Thepplicant rrwat call for all required inspe tions. Cortlplete drawing on reverse side. r Sigr t d D _ -- Title:, ?' t" Y Date: FOR DEPARTMENT USE ONLY E `' rp iJ Application Accepted by Date Area AIA Pit�r Grout Inspection by // Date Final inspection by Data Additional Comments: 11 �� IVOT(,Ci 6 C L]�4 i�y �CG7Z7 IT l�Ll �'1� ifU_TISCIl�(a �cytl 7 lct({rzlv�y ❑ Stk 466-6781 ❑ Lodi 359-3621 ❑ 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 j FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY —7`DATE PERMIT'NO. + EH 73-24 1EV.10/93) ` //� , �s -9-13 EH 1426 1 5 _75414