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APPLICATION FOR PERMIT k SAN JOAQUIN LOCAL HEALTH DISTRICT 1601. E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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. e , �If9 c 1< 'ON J Job Address A r ir1 , yy City �� y Lot Size � PM Owner's Name /"rGt►Add rr S U —TSL .,_ Phone Contractor's Name O / License No. .�� _ Phon TYPE OF WELL/PUMP:- --- NEW WELL zWELL REPL-ACEMEN) � DESTRUCTION•❑ PUMP INSTALLATION SYSTEM-REPAIR OTHER ❑: + DISTANCE TO NEAREST: SEPTIC TANK $EWER LINES lviV DISPOSAL FL[��PROP. LINE/�L—/✓1C� FOUNDATION �ZpIQ-07- AGRICULTURE WELL JHER WELL PITS/SUMPS�ONe_ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial2KPen Bottom ❑ Manteca Dia. of Well Excavation f �.a Dia. of Well Casing >60mestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing ! Specifications Cl Public ❑ Other ❑ Delta Depth of Grout SealC1 Type of Grout ❑ Irrigation _--Approx. Depth ❑ Eastern Surface Seal Installed Repair Work Done oo' Type of Pump H.P. z/a State Vyork Done ,t— Well Destruction I/ Well Diameter AR _ �Sealing Material (top,50' t lei ,0i1! Depth_42 Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet./ L 1..- Installation will serve: Residence_ Commercial - Other >�F- Number of living units: Number of bedrooms A Character of soil to a depth of 3 feet: ` Water table depth 1? SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments I PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line rDd) LEACHING LINE ❑ No. & Length of lines , Total length/size ! FILTER BED ❑ Distance to nearest: . Well Foundation Property Line (� SEEPAGE PITS ❑ Depth Size i Number SUMPS ❑ Distance to nearest: Well Foundation �4 Property Line .f DISPOSAL PONDS pr." 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 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 st call for all required inspections. Cplete drawing on reverse side. Signed 404,1 er_" Title:&a - Date: / FOR DEPARTM NT USE ONLY Application Accepted by W _ Date Area Pit or Grout Inspection by _ SDate Final Inspection by Date-�CL�1b Ad itional Comments: tk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Apblicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 k FEE AMOUNTDUE AMOUNT REMITTED RECEIVED BY DATE PERMIT`N0. INFO C + EH 13.24(REV.10183) EH 14-28 1,97, z� 1