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t i a I APPLICATION} FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 i � PERMIT EXPIRES 1'YEAR FROM DATE ISSUED -v (Complete in Triplicate) ` 988 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'off,the%San,Joa`qui� Local Health District. Job Address DOCG. City d `s`1!0�4ize PM Owner's Name Address Phone Contractor U Address D`� �G GZ_ r1Gc-� License fVo, Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ j DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ` FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS s INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i Industrial . ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing (Domestic/Private . i] Gravel Pack'. , t ❑-Tracy°ra Type-of Casing Specifications ('l Public. _Cl.Other ❑ Delta Depth of Grout Seal Type of Grout r I h Irrigation t _ _Approx. Depth LI Eastern Surface Seal Installed by _ _ 1 Repair Work Done Type of Pump ny!'� H.P. State Work Done C- - 1 Well Destruction 1'O Well Diameter Sealing Material (top 50') Depth Filler Material, 50') TYPE OF SEPTIC WORK: NEW INSTALLATION i-1. -REPAIR/ADDITION I 1 DESTRUCTION I } INo septic system permitted if public sewer is � available within 200 feet.) Installation will sehre: Residence_"Commercial Other Number of living units: Number of bedrooms3 f i Character of soil to a depth of 3 feet: Water table depth 1 SEPTIC TANK 1� ❑ iType/Mfg Capacity No. Compartments r PKG. TREATMENT'P-.LT. El ' Method of Disposal (Distance to nearest: Well Foundation Property Line Nim LEACHING LINE ❑ No. & Length of lines tt'' Total length/size '"FILTER BED �, ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS !+ l I Depth Size Number I SUMPS ] Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS I _❑- 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 r 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 rformance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- tion laws of California." i The ap nt m t call for all requir specti S. Com a drawing on arse side. Signed X r Title: T�_-. _.C9 S, �. _ __- Date: A _ FOR DEPARTMENT USE ONLY Lo Application Accepted by ' Date ft__� Area Pit or Grout Inspection by Dae Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 El 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 IFEE NFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. E + EH 134(REV.iin5) EH -2