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S' APPLICATION FOR PERMIT AIN d r SAN JOAQUIN-LOCAL HEALTH DISTRICT (r-.4� 1601 E. HAZELLTON AVE., STOCKTON, CA [�1! Telephone (209) 466-6781 a< PERMIT EXPIRES 1 YEAR FROM DATE ISSUED WAAW;2 7 1 87 4 (Complete.in Triplicate) :... RpM,E.NTA L HEALTH r Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the wdtit h rj� �}T�pllication is pp ��id1Y5 iif'th 'S'�h made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1562 for well/pump and the Rules a I Joaquin Local Health District. �( Job Address V �' " ' -- City Lot Size PM Owner's NarneAddress 24 U)I!M�m wev-A�/ _exone NWD [ y .1s � F Contractor's Name 6A% — lY� C+"License No. 1 �V Phone TYPE OF WELL/PUMP: NEW WELL © WELL REPLACEMENT ❑ DESTRUCTION ❑ r PUMP INSTALLATION�I SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION,SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Weil Excavation Dia. of Well Casing X Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 11 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ` ❑ Irrigation --Approx.-..Depth Eastern Surface Seal Installed by Repair Work Done C] Type of Pump — H•P• kII State Work Done `Well Destruction ❑ Well Diarrieter. Sealing MaterAl (top 501 x Depth Filler Material (Below 501 i 04 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:`i Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments: �•• PKG. TREATMENT PLT. ❑ Method of Disposal.;"A " 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 Cl Depth Size Number r 'SUMPS ❑ Distance to nearest: Well Foundation Property Line 21.. DISPOSAL PONDS ❑ i' I hereby certify that I have prepared tliidappiicatidn arid 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: - - T-�- w ��4 -� — �---•_-� Home owner or licensed agents 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."r Contractor's hiring or sub-contracting signature certifies the f I wing: "I certify that in the performance-of thefwork for which-this{permit is issued, I shall;employ persons subject to workman's compensa- tion laws of al ornia." The applica ti ust';a lI f Il r it i s tion Complete drawing on reverse side. GT Signed X Title: SEt, � Date:T ` FOR DEPARTMENT USE ONLY / 2_0 [� Application Accepted by Date 0"3 Area Pit or Grout Inspection by Date Final Inspection by Date- Comments: ate—Comments: j f' ❑ 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 GASH RECEIVED BY DATE PERMIT•NO. INFO + EH 13-24IREV"10183} 'rS7 _ EH 14.26