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r, APPLICATION FOR PERMIT , SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL I 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. Job Address CitY Lot Size — PM =. �3��i v/ '�`• Owner's Name Address Phone /�df�J lLy�rZ Address Contractor Phone 6s' Z6i6 TYPE OF WELL/PUMP: NEW WELL 171 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ r SYSTEM REPAIR ❑ OTHER ❑ i DISTA NEAREST: ,$EPIC SANK SEWER LINES DIS�OSAL FLD. PROP. LINE i y ,x 1 _ DATION +axxx � - --AGRICULTURE VIlELLN�+r.T 4 OTHER WELL i PITS/SUMPS INTENDED USE TYPE OF WELL _i CONSTRUCTION SPECIFICATIONS ❑ Industrial O Open Bottom ❑ Manteca Uiacrof ° ( Dia. of Well Calig 1 4 ❑ Domestic/Private © Grayel Pack�':> ❑ Tracy Type of Casin } Specifications t ! ❑ Public L2Other LlDelta Depth of Grout Seal } Grout�� r ��A�� 11 Irrigation � pi6x. Depth ❑ Eastern Surface Seal Insialle-b'by,- � �# Repair Work Done ❑ Type of Pump H.P. StatB Work'Done / f Well Destruction ❑ Well Diameter Sealing Material (top 501 [ x J Depth Filler Material (Below 509 ?' - ' TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITIO DESTRUCTION ❑ (No septic systeni,perrAtted if public sewer is available within 200 feet. y Installation will serve: Residence_ Commercial_ Other � a f Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water t ble dept –22 SEPTIC TANK ❑ Type/Mfg Capacity No..-Compartments' PKG. TREATMENT PLT. ❑ //Method of D1posal Distance to nearest: Well Foundation Property Line -p LEACHING LINE No. &Length of lines l rd - Total length/sizes T i I FILTER SED ❑ Dista ntce to nearest: Well� Foundation Property Line SEEPAGE PITS ❑f Qepth Size ,Number r SUMPS [J/ Distance to nearest: Well Foundation rf Proerty Line f DISPOSAL PONDS i] t f f I hereby certify that I have prepared this application and that the work will be done in a,6cordance with San Joaquin county ordinances, state laws, and rules and regulations of tleSa Joaquin Local Health District. 1 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 insuch man�ler as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature k certifies the following: "I certify Khat in the performance of the work for which this permit is issued,I shall empioy'persons subject to workman's compensa- tion [aws of California." \` ! # The applicant must call for d ins tion plete drawing on reverse side. Signed t Title: Date: 7r 7 FOR DEPARTMENT USE ONLY i ' QLD Application Accepted by Date Area 01 Pit or Grout Inspection by Date Final Inspection by Data s 7-do k 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 ;f I t I TV FEE AMOUNT DUE AMOUNT RE ITTED ASM RECEIVED BY ] DATE PERMIT NO. INFO + EH13-24(REV.1/95) �- EH 14-26 ! V i