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s e� ) APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT c 1601 E. HAZELTON AVE., STOCKTON, CA IV p 0-� Telephone 12091 466-6781 [� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED tu]�ZV 4 (Complete in Triplicate), q: 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. ' 'q. b 1 :Fra.. .,r Job Address 17 City s rel Lot Size PM Owner's Name f�l1K/�L �sS��' Address'/r/J 74rJ9'a w!t Pho - /PGne 4 rr I Contractor s�4 l � Address License No. Phone t TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ (1 tr DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE �9 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 LlEastern Surface Seal Installed by i Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') i Depth i Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION INo septic system permitted if public sewer is t available within 200 feet.) Installation will serve: Residence L1 Commercial Other Number of living units: Number of bedrooms T Character of soil to a depth of 3 feet:{ `- Water table depth SEPTIC TANK ❑ Type/Mfg Capacity l No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal I Distance to nearest: Well Foundation 1 Property Line LEACHING LINE ❑ No. & Length of lines + Total length/size ` FILTER BED .❑ Distance to nearest: Well Foundation Property tine } SEEPAGE PITS ❑ Depth r Size Number 1 �. SUMPS ❑. 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."Contractor's hiring or sub-contracting signature certifies the following: "I certify that in tAe performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." it S The applican must call for all required inspections. Complete drawing on reverse side. F $R L car /' `$ Signe X Title: !/ Date: F ARTMENT USE ONLY Application Accepted by (L _ Date Area Pit or Grout Inspection by Date Final Inspection by i Data r _ � Additional Comments: ❑ Stk 466-678.1...__ . . .❑.Lodi 369-3621--,._. ❑ Manteca -•823-7104, d Tracy 839-5385 -- Applicant Applicant- Return all copies to: Environmental Health Permit/Service's 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT D-U-�E:1 AMOUNT REMITTED CK H RECEIVED BY' DATE PEtMIT'NO. INFO + EH 1324(REV.1/R51 � 00 EH 14-28 (((