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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED a (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. pp��J/ nA Job Address oz:, rOY- � A/I/�i�.//�'$�j1, City 57 J"Aj(Q Lot Size pM Owner's Namet.1�.SS/�t� /�/0 i�/L� Add. Phone ContractorA .P"ivy' &XZE Address O,Zo�� 4<2/4Gd xLicense No. Phone- TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION TEM 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 Dia. of Well Casing Domestic/Private, ❑ Gravel Pack Tracy Type of Casing Specifications N Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump fi 108 H.P. -2_7 State Work Done PULL An'5 Jl/JFi / ^ Well Destruction ❑ Well Diameter Sealing Material (top 501 $ >�V!�'/Al S5Y/V / AAETAO V 1 Depth Filler Material (Below 50 -7/s7, _n TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is Vim[ ,[ available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: _ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth r� SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth -,Size Number SUMPS ❑ 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, 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." The applicant m t II f r all re uifed inspections. Complete drawing onnrevve/rsee do Signed X • se Title: i%/eJ Date: \� FO�R �D,E�PPARR�JJ_NENT USE ONLY Application Acceptei by Date 4'0 Area o C1 i Pit or Grout Inspection by Date Final Inspection by Date } Additional Comments: ❑ Stk 466-6781 ❑ Lodi 389.3821 ❑ Mlinteca 823-7104 ❑ Tracy 835.83W Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMGUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. E ♦ EH IX241RE .1/95) -7/l Qy EH 14Ze "7 l