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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT �C y 1601 E. HAZELTON AVE., STOCKTON, CA 5� Telephone (209) 466-67$1 AN �p 984 I 0 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED y�Crnmv epi (Complete in Triplicate) AZ � Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This San Jocation is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1 Bu for well/pump and the Rules and Regulations of the Sae aQ6:rr Local Health District. Job Address City E& Lot Size Pi`f I Q f,h'1 Ph � one,._ Owner's Name Address Contr'actor's;Name 'L ' .,S / c � License No. P�one 8 9 r+ TYPE OF-WELL/PUMP: l ` NEW'WELL 1-1 WELL REPLACEMENT L1DESTRUCTION ❑ _ PUMP INSTALLATION ❑ SYSTEM REPAIR 09 OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEINER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL t 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 �❑ Eastern Surface Seal Installed by Repair Work Done .JR Type of Pump A%, H.P. 1. j "', • State Work Done e y i Weil Destruction ❑ Well Diameter Sealing Material (top 501 Depth , Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION'❑"REPAIRIADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is w available within 200 feet./ Installation will serve: Residence— Commercial— Others (� 1 Number of living units: Number of bedrooms `Character of soil to a depth of 3 feet:. Water table depth !SEPTIC TANK` ❑A. Type/Mfg ` s Capacity No. Compartments { J 'Method of Disposal PKG. TREATMPL ENT T. ❑" `;', t Distanceto nearest:. Well i Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Y Foundation Property Line I SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPO'SAI: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."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 applica ' at II for 11 r uir i spections. Complete drawing on reverse side. I Signed Title:;7 ..- 1 Date: FOR DEPARTMENT USE ONLY r/ C I l�` S��r Area Application Accepted by Date f � I Pit or Grout Inspection by EDate Final Inspection b Date Additional Comments: 1 ❑ Stk 466-6781 ❑ Lodi 3643621 Manteca 823-7104 ❑ Tracy 83 Applicant- Return all copies to: Environmental ealth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEEAMOUNT DUE AMOUNT REMITTED. CASH RECEIVED BY DATE PERMIT"NO. INFO G @� + !H!32 S I c_ '!{REV.101831 ,� ��'Z_g• -