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APPLICATION FOR-PERMIT - ! SAN JOAQUIN LOCAL HEALTH DISTRICT . 1601 E. HAZZ.E i ONN. AVE:,,';•STOCKTON, CA Telephone (209)"466-6781 PERMIT EXPIRES 1'YEAR,FROM-DATE ISSUED' (Complete'in Triplicate):"` c,Lr 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. x sD 1 771J Job Address �J I ✓��f�'A SWr 04_ City' 01-Ct f Lot Size :l#` ) PM -Owners Name 1 -. I, Address Phone. . 5.7 Contractor A L 1;P r Address �"�" 0O u ' License No. 173_ a.Phi bne 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 INTENDED USE TY.PE_OF WELL--......PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private i,:",C] Gravel Pack ❑ Tracy Type of Casing 'Specifications i ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of-Grout ❑ Irrigation Approx. Depth ❑ Eastern J,.;,-iSurface Seal Installed by Repair Work Done ❑_ Type_ of Pump 1 L H.P. J* y! State Work Done Well Destruction ❑ Well Diameter - Sealing Material(top 50')� �k Depth � = f Filler Material (Below 501 'F+ J TYPE OF SEPTIC WORK: NEW INSTALLATION'❑ REPAIR/ADDITION .DESTRUCTION EJ (No septic system permitted if public sewer is N available within 200 feet.) Installation will serve: Residence_ Commercial_ Other { Number of living units: I 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; 67 Distance to nearest: Well Foundation Property Line LEACHING LINE No. & Length of lines IC ko Total length/size FILTER BED Distance to nearest: Well Foundation_._ Property Line SEEPAGE PITS ❑ Depth Size Number, _.__-_ ' SUMPS ❑ Distance to nearest: Well Foundation 'Propgrty.Line DISPOSAL PONDS ❑ mow jP 1 t t hereby certify that I have prepared this application`and that-the work Will-be-done in acco-rdance with San Joaquin'county ordinances, state laws, and y rules and regulations of the San Joaquin Local Health District. ' F.; 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'workmah s compensation!laws of California." CofitriiAor's hiring'oi sub-contracting signature 'certifies the following:"I certify!hat in the performance of the work for which this{permit is issued,'t shall emlooyipersons subject to workman's compensa- tion laws of California." t The applicant must call for all required inspections. Complete drawing on reverse side. Si-ned'X �. --- - file:ww:..w• L... a -.,-. �w....w�. __.—,�_._...�«,M•,...�w�-c.+a-r-...�.,,�.�r g ,. I/tiw_ 1 .,-��- .�— Title:�.Pii�?� Date: FOR D_EPARTMENT-'USE QNLY)% ..-.-^App icatibn-Accepted Wy Dale'"- - __._w- Pit or Grout Inspection by' V Date Final Inspection by ' Date�� Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Heath Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95.201 FEE INFO AMOUNT DUE ' - AMOUNT REMITTED CK CASH RECEIVED BY. DATE PERMIT`NO. + EH 1324[REV.1/a 51 .. a .•a;-- - .. `'�/� gs 7 ' EH 14-26 - '