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4 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 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. Job Address pp y City,,,, � ��// Lot Size PM Owner's Name Address �.1��D 8GVLG( iJ _ /•I �� one � "�3 TC Contractor's Name I License No. Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑. SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD./aW 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 M jog Dia. of Well Casing Domestic/Private Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other C1 Delta Depth of Grout Seal ��2f T pe pf Grout ED Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done # Well Destruction 171 Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION ElREPAIR/ADDITION ❑ DESTRUCTION C1 (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 r Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method o a Distance to nearest: Well Foundation Property Line 'UT ^� .. LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line .1111 q 2 2 1985 SEEPAGE PITS ❑ Depth Size Number ENV{RC3�I.4 riT1-�1L HEALTH SUMPS ❑ Distance to nearest: Well Foundation Property Line___ ERIV,I /SERVICES 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 thi permit is issued,I shall employ persons subject to workman's compensa- tion laws of Ca'fornia." The appl'c ust call for all requi inspections. mplete drawing on re e. Signed Title: Date: 7 A75 FOR EPARTMENT SE ONLY L Application Accepted by Data _ zZ�� Area% o Pit or Grout Inspection by ate Final Inspection by A1/4 I' 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 INFO AMOUNT DUE AMOUNT REMITTED '/CASH RECEIVED BY DATE PERMIT•NO. a EH 1324 1AEV.}0la31 `Y�� f t,{�– 1\fir') -7-22– R! – F95-3 �EH 14-26 6666 1 1 V/