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APPLICATION FOR PERMIT �^ aAN JOAQUIN LOCAL HEALTH DIS R4# 1601 E. HAZELTON AVE., STOCKTO � �� /�J Telephone (209) 466-6781 `� `-- PERMIT EXPIRES 1 YEAR FROM DATE IJMW (Complete in Triplicate) 11 6 AA'' Application is hereby made to the San Joaquin Local Health District for a permit to construct and or INV woxk.hPrP7ri1,z his application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/l:9wop-spai. 71 thp ,Rn inanuini Local Health District. ��11 C I Job Address 6Z I ��S"r CLAS( City Lot Size PM Owner's Name WEST 0-t� ?wFRTIGAddress F 0 00X G 1 SZ_1 STOC'KTD/J 55�oPhone�� "03 .70CK_TVtJ 01-97 IS Contractor �PGAddress License No. SI Z2(oS Phone 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 ❑ Manteca Dia. of Well Excavation ,111 Dia. of Well Casing Z AC me tic/Pri�t�� Gravel Pack ❑ Tracy Type of Casing VqG sc� T� Specifications ��TTbb ' ur f-1 ublic Cl Other ❑ Delta Depth of Grout Seal 37 �(7 Type of Grout 1 1 Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done Ll Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') _ TYPE OF SEPTIC WOR NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: Number of s Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation - Property Line LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS L-1 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 la ifornia." The plicant m st call for all require ns ctions. Complete drawing on reverse side. Signed XX Title: 1 Date: FOR TMENT USE ONLY Application Accepted by Date l Area ! �� Pit or Grout Inspection by 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. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 .�� FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO CASH R�yye� + EH 13-24(REV.r i rt 51 O p pp 7 ,r7, !/ r EH 14-29 7