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PO1 A,r"� c_�•,_� APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 4 PAYMENT 1601 E. HAZELTON AVE., STOCKTON, CA RECEIVED Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED NOV 11988 (Complete in Triplicate) v Ap i hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is ma _a.ft*County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Hea� +xb��, V Job Address mt City Lot Size PM Owner's Name.�G �1 �!.�, _.,, Address 2 ` Phone (Z09 2ft2Contractor rJ/e7Address ¢- License No. Phone _q4441� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER \1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. 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 . Dia. of Well Casing [Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done It Type of Pump4 H.P. I State Work Done Atli Well Destruction ❑ Well Diameter Sealing Material [top 501 � / Depth Filler Material (Below 50'),--./ !�� — TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/AFIDITION•❑- DESTRUCTION 0-(No septic system permitted if public-sewer is : r 1 ` 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 - 1 Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: We-II , Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well _ 3 Foundation Property Line SEEPAGE PITS ❑ Depth Size.: Number SUMPS El Distance to nearest: Well.� I Foundation ._Property Line DISPOSAL PONDS ❑ 1 V 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. I I 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 peimit is issued, I shall employ persons subject to workman's compensa- tion laws of California." I The applicant must cal for equired inspections. Complete drawing o verse side. Signed � Title: J date:1-/� z FOR DEPARTMENT USE ONLY J Application Accepted by Date�r , Area Pit or Grout Inspection by Date 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 AMOUNT DUE AMOUNT REMITTED C�A�SH INFO RECEIVED BY DATE PERMIT"NO. + EH13-24(REv.1/$5) `-► C JS�� aC(� /`� �/_ A EH 1426 ! C I