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i:. l t �+ APPLICATION FOR PERMIT t`J SAN JOAQUIN.LOCAL'HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA } Telephone (209) 466-6781 ` l PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ' f b. ,.' (Complete in Triplicate) k 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 Rtjles and Regulations of the San Joaquin Local Health District.' } t ' PM Job Address 5 ��'S. i� d� tY � S=-777 Owner's Name 'Address Contractor vw � Address" License No. Z.'��}3_Y Phone — t TYPE OF WELL/PUMP: NEW"WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ j PUMP INSTALLATION 71SYSTEM REPAIR El OTHER 1-1 F DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD• . PROP. LINE 1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE STYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFIC .`� - " 'iI ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia'of Wekl Casing ❑ Domestic/Private r ❑ Gravel Pack ❑ Tracy Type of Casing Specifications t �f + Type of Grout E P �; ❑ Public ��•� ❑ Other �4 ❑ Delta Depth of Grout Seal I YP.� i ❑ irrigation j I_�pprcx: Depth ❑ Eastern Surface Seal Installed by ' State Work Done i Repair Work Done ❑ Type of Pump "` HP Well Destruction ❑ , V1.el1 Diameter ` Sealing'Material (top" & "'- Depth Depth 1 i" Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION I❑ (No septic system permitted if public sewer is L � available within 200 feet.) - Installation will serve Residence G Commercial_X_ Other Number of living units: A Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK :i ] Type \ ig Capacity No. Compartments PKG. TREATMENT�PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line s ae LEACHING LINE ' ❑ No. & Length of kines�+, Total lenth/sizi. g FILTER BED . ❑ Distance to,nearest: �Welk Foundation Property Line ` !r SEEPAGE PITS ' Depth Number I SUMPS Ll Distance to nearest:rt Well 4- ~'Foundation Property Line DISPOSAL PONDS �� ❑ .ti 1 . I`� +- �ti I hereby certify that I have prepared this.application and'thavthe work wifl be done in accordance with San Joaquin county ordinances, state laws, and I rules and regulations of the San Joaquin Local Health District• i -ki, Home owner or licensed agent's signature certifies the following: "IJ ceffly,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." Contractors hiring or subcontracting signature certifies the following: '9 certify that in the performance of the work for which this permit is issu&d,4_shall employ persons subject,to workman's compensa- tion laws of California." The applicant must call for a wired inspectio C fete drawing on_reverse side. Signed,N, Title: Date: DEPARTMENT USE ONLY 77— Application Accepted by -4 �ILI�H� � Date � "a' r Area_ � 'J " Pit or Grout Inspection b4 Date Fin al I spe tion by )e v F O Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 Manteca 823-7104 ❑ Tracy 8M35- 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 CK CASH RECEIVED BY DATE PERMIT'NO. INFO + EH 13-24(REV.t/85) .- - 77�/ a EH 14-26