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APPLICATION FOR PERMIT 41 i SAN JOAQUIN LOCAL HEALTH DISTRICT JAN ff�� 1601 E. HAZEL T ON AVE., STOCKTON, CA �3So Telephone (209) 466-6781 "()AQtf"N LOC4L PERMIT EXPIRES 1 YEAR FROM DATE ISSUED L)157RICT (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. / I i Job Address /e�+�"f- ��G[�/� d N city g of Size PM ,!4' Owner's Name �&_r'e P&al-(04. Address f� Phone "' Q i � r Contractor's Name License No. ��L 3 .S2 b I Phone v f6.z TYPE OF WELL/PUMP: j *► NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ w DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE - FOUNDATION AGRICULTURE WELL'—'OTHER WELL"_- PITS/SUMPS w1` INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial i I ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing U1050-mestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout D Irrigation { ---Approx. Depth ❑.Eastern Surface Seal Installed by Of Repair Work Done ��Type of Pump _ H.P. State Work Done , Well Destruction D Well Diameter Sealing Material (top 501 Depth Filler Material jBelow 50') TYPE OF SEPTI WORK:NEW INSTALLATION 171REPAIR/ADDITION El DESTRUCTION ❑ (No septic system permitted if public sewer is r n available within 200 feet.) v 1 Installation will serve�' Residence_ Commercial_ Other Q Number of living units: ' Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK I ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal' Distance to nearest: -Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line , SEEPAGE PITS1 ❑ Depth Size Number SUMPS I ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ .- '.y «..v.�; - _y wY. = . .� —. ..�,: ��.�; ` 4 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. Home owner or'ii ent'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 pe n in such anner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the lowing: "I ce fy that in the performance of th rk for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws California." � 1 The appli ant must o II require in awing on rev r /,/a r AL Signed Title: Date: FOR DEPARTMENT USE ONLY ` [� 's`� / —�2�T Application Accepted by 'V p�/ Date Area j Pit or Grout Inspection by IA Date Final Inspection by Date / .r1 •» Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 82:3-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE CK 9 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. + EH 1324(REV.10183) EH 1426