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APPLICATION FOR PERMIT �J+ SAN JOAQUIN LOCAL HEALTH DISTRICT AU G 2 2 jc a4 A 1601 E. HAZEL T ON AVE., STOCKTON, CA a Telephone (209) 466-67$1 SAN JOAQUIN LOCA 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 Sari Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health Distrix Job Address G -,L ClE�� City k Lot Size O Ace* PM Owner's Name)yw ply Address 3�/Sl (13AQ/!t — AcJ7 phone 36 Contractor's Name A License No. �� Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: _TANK/OIO Fl SEWER LINES &&P ' DISPOSAL FLD »..,...- SEPTIC--.._ tZr,'_ PROP. LINE`_—_ FOUNDATION � AGRICULTURE WELL OTHER WELL PITS/SUMPS 4 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS dustrial ❑ Open Bottom 77 Manteca Dia. of Well Excavation 1"' Dia. .ofi.Wejl+Casing �^ omestic/Private 'Gravel Pack ❑ Tracy Type of Casing tJe T , ��j 9 a ications X41 � Public ❑ Offer ❑ Delta Depth of Grout Seal Fr Type of Grout CC*"elf ❑ Irrigation y09—f—�4pprox. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump S%4- . H.P. _/Q � State Work Done r- Well Destruction D Well Diameter Sealing Material (top 50') Depth Filler Material f8elow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (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 i Character of soil to a depth of 3 feet: V Water table depth .� SEPTIC TANK ❑ 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 ❑ Depth Size Number 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 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 must call for all required inspections. Complete drawing on reverse side. Signed Title:. vim'fYIL Date: -9--20- 8A:4 FOR DEPA TMENT USE ONLY ' p Application Accepted by Date a 2 a 7 Area �` �'•' Pit or GIP Inspection byDate �' Final Inspection by t Date II Additional Comments: q4& ❑ 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 CK INFO AMOUNT �DUE � AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. O a SS� -EOgS + EH 1324(REV.10!83) EH 1428