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.M APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r _ 5 A -c,E�) 4_�q (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 or sewage or No. 1862 for eil/p p a t e ules and Rp lations of the J n Local Heal Dist' t ` �„�( o,, �, .Q � /c2 SGC. ��L� V � Job Address, All/ � City 4 Lot Size�©�A A&AolM + Owner's Name fi;A ^/&Z� Address l K7 Phon Contractor's Name icense No. 7l7 1/ L Phone r 4] TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION X SYSTEM REPAIR E] OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK iiii////�'"' SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION 1 AGRICULTURE WELL-- OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL -PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Weli.Casing 44IIIn� Domestic/Private El Gravel Pack ❑ Tracy Type of Casing Specifications y! I7bliEl ❑ Delta Depth-of Grout Seal Type of Grout u . rrigatc ion �Approx. Depth Eastern l - urface Seal Installed by Repair Work Done' 03 Type of Pump �= H.P "' _ State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') , Depth 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.) Installation will serve: Residence— Commercial_ Other } Number of living units: Number of bedrooms J Character of soil to a depth of 3 feet: , 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 E1 Distance to nearest: Well f 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 favus, 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." Contractoi'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 applican must cal or all required inspecti s. Complete drawing on reverse sit Signed Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date �r II Area Ph or Grout Inspection by Date ;Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 f ❑ Tracy 83545385 Applicant- Return all copies-to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED SH RECEIVED BY �y DATE PERMIT"NO. +EH13-24(REV.10!83) EH 1428 l