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— APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I (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. p' ] /M Job Address �, ��/ !� /�-, City Lot Size_Z- v/MM Owner's Name ddress�-,--76 Phone �/ Contractor's Name License No. a UCr� Y Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ I PUMP INSTALLATION ❑ SYSTEM REPAIR El OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 1 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 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta-----epth-of-Grout-Seal—� Type of Grout I ❑ Irrigation �4pprox. Depth ❑ Eastern Surface Seal Installed by Q Repair Work Done ❑t Type of Pump - 1H.P. State Work Done C Well Destruction ❑-.Well Diameter" { l Sealing Material (top 501 { 1 Deptli �. Filler Material (Below"50'),, TYPE-OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ INo septic system permitted if ipublic sewer is r . A 1 f available within 200 feet.) +I j Installation will serve:J-Res(den a/_L.__ Commercial Other Number of livingnits: Number of a omsZr / Character-of soil WNa depth of 3 feet: Water table depth f r SEPTIC TANK ❑ Type/Mfg apacity Q No. Compartments PKG. TREATMENT PLT. ❑ � Method of Disposal Distance to nearest: Well; Foundation 0 Property Line jD I LEACHING LINE ❑ No. & Length of lines s 9 total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size !Number— � - t1 SUMPS X Distance to nearest: Well' Foundation Property Line DISPOSAL PONDS ❑ ! 1 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,land. 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 F" . employ any person in such manner as to become subject to workman's compensation laws of California."C6n3tractor's hieing 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 -to workman's compehsa- tion laws of California." a � r ; The applicant call for all required inspections. Complete draWing'on reverse side. �.i Signed X Title: _:-c ��[ Date: YD — FOR`DEPARTMENT USE`ONLY Application Accepted by ------yArea Date ' J Pit or Grout Inspection by ,lA," Date .-. Final inspection by Date _. Additional Comments: ❑ Stk 466.67$1 ❑ Lodi 369-3621 ❑ Manteda 823-7104 ❑ Tracy 835-M j t. 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 ' A H RECEIVED BY DATE— PERMIIT'NO. € + EH73-24{REV, 10/83) `S, h 0-33 -957 E1414-26 Y