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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICTPA 1601 E. HAZELTON AVE., STOCKTON, CA necE VET Telephone (209) 466�r38T 'Y6 g--.3y0� D PERMIT EXPIRES 1'YEAR FROM DATE ISSUED AUG 2 19$8 (Complete in Triplicate) Zwk Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the wor t lication is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rule ftn� � Joaquin Local Health District. Job Address �¢ /"'�� v//� City Lot Size PM Owner's Name ,�/&G L (1012116/ICt&A) Address Zlr-!�� 'S/u✓`1 �✓�- J10- hone D —67rf,46 Contractor / Address2ZQNFST. M,C,4—License No.283326 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER IX/U1'k>,riP Old DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE O' FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS O INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom Cl Manteca Dia. of Well Excavation f0 — Dia. of Well Casing Domestic rivate Gravel Pack ❑ Tracy Type of Casing p V C Specifications M Public fl Otter rl Delta Depth of Grout Seal �' _ Type of Grout ��/'1 � I I Irrigation —4Q Approx. Depth I I Eastern Surface Seal Installed by CArz:,bel _ Repair Work Done U Type of Pump �!� H.P. _ Q ___. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth ti4�� Filler Material (Below 501A TYPE OF SEPTIC WORK: NEW INSTALLATION I I R1PAIRiADDITION I I DESTRUCTION I I (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 PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines _ Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size _- Number SUMPS Ll 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."Contractors 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 t c for uired inspections. Complete drawing on reverse side.l ,�yn/C%K'C/^P/Q K? Signed X �� l Title: Date: N FOR DEPARTMENT USE ONLY Q pp Application Accepted by r 0, I S Date D's —D 0 Area Pit or Grout Inspection by Daru Final Inspection by 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�7DUE AMOUNT REMITTED CCK H RECEIVED BY DATE PERMIT'NO. . EH1I M 3-2 (REV.1/"51 �w s �� EH tl �� IIUU _ C)�