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r APPLICATION FOR PERMIT SAN JOAO.UIN LOCAL HEALTH DISTRICT PAYMENT 1601 E. HAZE T ON AVE., STOCKTON, CA R EG E t V E D Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED AUG 3 198$ (Complete in Triplicate) fWRONMF f Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein de*ERMI�Ff16~ g�i�tiTH made in compliance Oth San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the RgIes and Regulations of t uin Local Health District. �rry �} Job Address -,�G�� ,( y-t�� 9F .. City Lot Size PM Owner's Name Address J Phone V 6F Contractor E�.C!/�]G1J / -Address/1r7?7- �� License No. f) Phoneq. TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER EX 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 C�(_Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1 ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Dep ❑ Eastern Surface Seal Installed by Repair Work Done Type of Pump -I H.P. I 7 S ate Work Done es 7 l-_ �I Well Destruction ❑ Well Diameter Sealing Material (top.50') fir. Depth Filler Material (Below TYPE OF SEPTIC WORK; NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is 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 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments S PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line L LEACHING LINE C} No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line {T SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line C DISPOSAL PONDS ❑ 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 must call f 1 required inspections. Complete drawing on r rse side. Signed Title: _ 1�Yi��t _ Date: O DEP TMENT USE ONLY Application Accepted by C!/ Date __ Area `'t} Pit or Grout Inspection by Date Final Inspection by rC Jy� _ Date ' g 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 INFO ,,�-}}AMOUNT DUE AMOUNT REMIT-TED 1, , /CASH RRECEIVED 6Y DATE PERMtT"NO. fEH14-24IREV.rlssl p{ �- t.,'U ��3 j -`'`-' 1L<-1P3 �l P. -