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APPLICATION FOR PERMIT _ SAN JOAQUIN,LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED T 3 (Complete in Triplicate) 2—ID5-0dclD Z y 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. 18622 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address _]7u1J � oZ ( City Lot Size PM 1 Cv Owner's Name Address �S� Phone Jr'Z 3—��73 Contractor + Address. .s 1/79Gt z License No. cZ9f 0`3 Phone TYPE OF WELL/PUMP: V NEW WELL ) WELL REPLACEMENT ❑ DESTRUCTION ❑ -Y PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL w--y- OTHER WELL PITS/SUMPS — �! INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS /U !� C1 Industrial ❑ Open Bottom )l Manteca Dia. of Well Excavation Dia. of Well Casing i1 Domestic/Private Gravel Pack ❑ Tracy Type of Casing RV6 Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout SealQ Type Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump. H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') I Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑. REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted K public sewer is _ 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 LEACHING LINE O No. & Length of lines Total length/size FILTER'BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS. _ Ll_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 1 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." i The appli an ust call for all r uir inspectto . Complete awing on r arse side. Signed .Title: Date: R (DEPARTMENT US ONLY i Application Accepted by Date — 'U Area € Pit or Grout Inspection by ra6,z Date Final Inspection by Date Additional Comments: ❑ Stk X466-6761 ❑ Lodi 369-3621 ❑ Manteca t.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 AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT"NO. INFO 0-. i!CASH + EH 18-241REV.i/8 5) 1 0- 0� EH 1421 _