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f 0 APPLICATION FOR PERMIT y 1 SAN JOAQU,IN LOCAL HEALTH DISTRICT 1601 E. H—AAC- 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. 1 k Job AddressOt C� City Lot Size PM } . C`� , Owner's Name (�N �•�ss Z. Phone VI-7L—02 Contractor's Name cense No. LID Phone 6 Z TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PR:PP LINE \�\i " r 4 FOUNDATION AGRICULTURE WELL OTHER WELL _PITS/-SUEUPS.=T . f, �-�� - «�INTENI7ED U5E- ► i�ypE OF:WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS, ❑-IyA[istriak ❑ Open Bottom a. 'of W611 Excavation ia:,of Well Casing + "' Domestic/Private ❑ Gravel Pack ❑ Tracy f Type of Casing y Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Dep_tht ❑ Eastern Surface Seal Installed by 1 Repair Work Done P.Type of Pump V G'f` H.P: State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 ;w�, Depth Filler Material (Below 50') J,, TYPE OF SEPTIC WORK: NEW INSTALLATION.❑ REPAIR/ADDITION ❑ DESTRUCTION.,❑,,.(:oseptic system permitted if public sewer is ` ! available within 200 feet.) Installation will-serve: Residence_ CommercialOther 7 x Number of living units: Number of bedrooms 1 Character of soil to a depth of 3 feet: I 4 Water table depth SEPTIC TANK ❑ Type/Mfgf Capacity h v i No. Compartments PKG, TREATMENT PLT. C1 ;j } Method of Disposal Distance to nearest: Well Foundation I Property Line v LEACHING LINE ❑ No. & Length of lines Taf31 length/size �� FILTER BED ❑ Distance to'nearest: Well Foundation Property Lie .� SEEPAGE PITS ❑ Depth j Size Number i SUMPS ❑ Distance toynearest: Well Foundation Property Line 41 DISPOSAL PONDS ❑ I' r --il'hereby-certify-that-Phave-prepared-this application••and-that the work'will"be-done in accoTdarice with-Sart-JU6 umcounty-o�dihances, state laws,a—� 4 rules and regulations of the San Joaquin Local Health District. I Home owner canse gent's signature certifies the following: i'I certify that in the performance of the work for which this permit is issued,.I shall not �_employ`.anq erson,in suc manner as to become subject workman's.compensation laws of California."Contractors hiring or sub-contracting signature certifies•t followln 1 :. h gl•c :tljat ih the pe ormanc f he work !orQhlch this permit is issued,I shall employ persons subject to workman's compensa- tion law of California." Thea !-cant ust cal all requi mplete dry ing on reverse si e. - t _ Signe Title" Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area c� Pit or Grout Inspection b �gDate Final�I^nspectionHby �' Date ' Additional Comments: d�� /�. I ❑ Stk 466-6781 ❑ Lodi 369-3621 10 Manteca 7.104 ❑ Tracy 835-6385 - Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE t } INFO AMOUNT DUE � AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT NO. + EH1324(REV. 10/83) {l ' EH 14-26 5 c5.7 I