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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781lN [� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED -,7-pll3 20_ ,3-37Z_01 7Z_O1 (Complete in Triplicate) —r19-WX_ t:VW_1 ON Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the wor c berein described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1B62 for well/pump and the Rules and Regulations of the San Joaquin Local Health District, LA11t WP '0- Al -klnrLleV) Glf1 I FOTLw�Ft Niru ISA-c_- Pfzopuc�� Job Address fQ0p City-`_AVftZAD?Lot Size PM Owner's NameAddress _ �/�� - `' `-" Phone Contracto,t ss 7wense No.5'/ Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER �� ;Oaj DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. --&-ZV J} f FOUNDATION AGRICULTURE WELL OTHER WELL PZS-A t6 7��5 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Ll Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ❑ Domestic/Private ❑ Gravel Pack L7 Tracy Type-of Casing I'] Public 1-1 Other ❑ Delta Depth of Grout Seal TYPr I 1 Irrigation _Approx. Depth l 1 Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P- State Work Dane Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIRlAODITION l I DESTRUCTION i 1 (No septic system permitted if public sewer is 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 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Ll 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 Di§trict. 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 applicantt call for all� inspections. Complete drawing on reverse side. XC, Signed Title: 960 Date: F R (DEPARTMENT USE ONLY Application Accepted by Data 71V Q Area Pit or Grout inspection by Date Final inspection by _-I Dat Additional Comments.. 9&r �" w "�' ElStk 466-6781 LILodi 369-3621 t Mant ca 823-7104 ❑ Tracy 835 5 ,�I„_ yl�p 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 CK RECEIVED BY DATE PERMIT-NO. ' INFO �^ CASH 7 + EH 13-24(REV.I/n s) © -)r v � EH 14-2e 1