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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA fcez Telephone (209) 466-6781A U PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENv��QI �� (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein descri6� "til LA Ir is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of to Joaquin Local Health District. ��cc Job Address VGA IL Cityl�� Lot Size PM Owner's Name Address S n7 .1/76 .. Phone Contractor . Q/ / *0'f Address /y License N04R_ZV10 Phon 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 TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom C7 Manteca Dia- of Well Excavation Dia. of Well Casing \ X"Domestic/Private ❑Gravel Pack ❑.Tracy Type of Casing Specifications 1"1 Public Other — - F1 Delta Depth of Grout Seal Type of Grout _ I 1 Irrigation Approx. DepthI I Eastern S rface Seal Installed by Repair Work Done Type of Pump �L — H,P. �.rState Work Donez-'ri.&"LL Sc."Mo Well Destruction ❑ Well Diameter Sealing Material atop 501 i Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I:) REPAIR/ADDITION I I DESTRUCTION i I (No septic system permitted it public sewer is r available within 200 feet.) �f) Installation will serve: Residence Commercial Other Number.of livingunits: Numberb'flbedrooms Character of-soil to a depth of 3 feet: `Water table depth SEPTIC TANK- ❑ T=e/Mf YP 9 Capacity No. Compartments PKG. TREATMENT PLT. ❑ {_ .� ,.i Method of Disposal Distance to nearest: Well Foundation Property Line r LEACHING LINE ❑ No. & Length of lines Total length/size � FILTER ZED ❑ Distance to nearest: Well Foundation Property Line k SEEPAGE PITS I 1 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 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,1 shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractors 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 applicant m call.for-all- wire inspections. Complete drawing on reverse side. �^- Signed X rw Title: (9-11�Z Date: * FO PART T USE ONLY Application Accepted by y Date —F Area Pit or Grout Inspection by Date Final Inspection Dat �1 Additionai Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 C1 Manteca 823-7104 ❑ Tracy 935-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601.E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT N0. a EH 13-24(REV.1/95) 16.01 � 4 - EH 14-28 7