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(� Y APPLICATION FOR PERMIT 1 SAN JOAQUIN LOCAL HEALTH DISTRICT w 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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 described.This application 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 the San Joaquin Local Health District. t Job Address + u 'v City11 Lot Size PM i�IS -F-1� Address� Phone �--"0 Owner's Name - - '- License No �7 &s -Phone Contractor 1�[ Address. _ 93a �7 =-.-- TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ J DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES } DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS f INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS El Industrial ❑ Open Bottom ❑ Manteca Dia.' of Well Excavation Dia. of Well Casing l Domestic/Private ! Gravel Pack ❑ Tracy., Type of Casing �VC lSpec'rfications .y 1-1Public El Other ❑ Delta (I Depth of Grout Seal- 16»- -;� TYpe'of-Grout-- ❑ Irrigation '.4Y5- Approx. Depth Q Eastern Surface Seal Installed by MA4-Thr IA Repair Work Done ❑ Type of Pump k/ `'`7 H.P. State Work Done_0 W M 4A Well Destruction ❑ Well Diameter ` ~ r Sealing Material4top 50`1 Depth Filler Material f13elow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No Septic system permitted if public sewer is Q f _4 available within 200 feefl Installation will serve: Residence_ Commerce al Other Number of living units: Number of bedroo}}ms Character of soil to a depth of 3 feet: 1 Water table depth SEPTIC TANK ❑ Type/Mfg tt,3 Capacity No. Compartments C PKG. TREATMENT PLT. ❑ } � Method of Disposal Q Distance to nearest--"% Well � Foundation Property Line LEACHING LINE ❑' No. & Length of lines 1. Total length/size .r FILTER BED ❑ Distance;to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well v Foundation Property Line DISPOSAL PONDS ❑ j 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, 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." 1 The applicant must call for all required inspections. Complete drawing on reverse side. 4 Title: Date: S-,o_G 0 Signed X f { �� A�RTMENT USE ONLY Applicaf Accepted by Date Area I Pi r Grout I spection 1 Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy" 835-6385 \` Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazeltdn Ave., P.D. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFOZK y . + EH 13.24SREV.1/85) `osc� pS pb -X75 -�✓7 CIO-I . i .�H 14-26