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APPLICATION FOR PERMIT +� SAN JOAQUIN LOCAL HEALTH DISTRICT 11 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE`ISSUED1 Ct7�ta' `f (Complete in Triplicate) y n 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.5;9 for sewagty"or"No. 1862 for well/.pump and the Ryles and Regulations of the San Joaquin Local Health District. Job Addresspt�l�� Lot Size PM 2 4 `.,Owner's Name ��_44--� Address Phone - L j 2'9�2C? Phone D. r�Cvntractbr " Cd- Address T � � 7 L7 � License No. Phone TYPE-OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ \� PUMP INSTALLATION L1 SYSTEM REPAIR L-1OTHER Ll i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE Z l'. FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑'Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth,„ L),Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump t f �/ H.P. State Work Done C]'1 Well Destruction ❑ Well Diameter l ��Sealing Material [top 501 Depthr_Material (Below,60') TYPE OF SEPTIC WORK: NEW INSTALLATION ElEPAIRa DDITION DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) i - Installation-will-serve;--Residence�--Commercial • Other- ........ -- - — ,-- ^- - Number of living units: lz2__ Number o bedrooms Water table depth ! Character of sail to a depth of 3 feet: w ' tom! SEPTIC TANK ❑ Type/Mfg Capacity +' 4No. Compartments Method of Dis PKG. TREATMENT PLT. ❑ ' l poral F. Z Distance to nearest: WellFoundation Property Line , 4 p LEACHING LINE 1-1 No. & Length of lines Total lengthYsize; FILTER BED ❑ Distance to nearest: Well .Foundation 1. Property_1ine SEEPAGE PITS G ❑ Depth —Size Number, - .l t� SUMPS- '� 1u -��f�0istance to nearest: Well� Found9tion "'""4`�� � '"'� Property.-Line L DISPOSAL PONDS Cl 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. I > 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 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 alifornia." The applicant st call for I required inspections. Complete drawing on tt neve a side. Signed ' Title: 11. - Date: " l R.DEPARTMENT USE ONLY J _ Application Accepted—byR�~ l - Date Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: I Cl Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.'@A95201 F AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO.-. . INFO CASH + EH 13-24(REV.1/85) 4 EH 1426 - r