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APPLICATION.FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE.,;STOCKTON, CA �I Telephone 12091 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED /Complete in Triplicate} w Application is hefeby 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. 1662 for well/pump and the Rules and Regulations of the-San Joaquin Local Health District. Job Address /V �� Ciry ( « " Lot Size PM Owner's Name �'rGf ra" 'O ✓ Address µ t �� -C>�GtJZPhone _��(6_3-27 Contractor ,�LZ C Address + Z� License No. Phone G(U l� TYPE OF WELL/PUMP:A NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION.❑-� �" f '"SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK t..SEWER LINES DISPOSAL FLD. PROP. LINE �n�l FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS j INTENDED USE TYPE"OF WELL-------PROBLEa-AREA CONSTRUCTION SPECIFlCAT16NS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing \ ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications `\v ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation __.L4pprox. Depth,h ❑ Easfer- ""µ ! 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 (Below 501 l TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION.❑ DESTRUCTION o septic system permitted if public sewer is ..--- ~~- i'-�"�' - I 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 i LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ -Distance to nearest: Well Foundation Property Line ,.,W-,SEEPAGE PITS ❑' Depth Size Number SUMPS ❑ . Distance to nearest:,-,Well -Foundation"----« Property Line DISPOSAL PONDS ❑ 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 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." 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 laws of California." The appli a ust call far req .add in s ti s. Complete drawing on reverse si . Signe L Title: L L" ` 4 _. Date: 3 FO P-ARTME USE ONLY 00 f Appfication Accepted by Date Area Pit or Grout Inspection by Data Final Inspection by _;-Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3611 0-Manteca 823-7104 . ❑ Tracy 835-6.365 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O.,"Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO + EH1324/REV. i H s� 1 - /:�«-7 87 J3 EH 14-26