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~ APPLICATION FOR PERMIT 1 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 'I YEAR FROM DATE ISSUED _3"q LOCAL 1 (Complete in Triplicate) `� ,f;.' rtj, R.1CT 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. a Job Address / 13 -73 //- eslr'�,4� City - Lot Siizze�.Q PM Owner's Name ss l - 3 d�u�cJ Phone !� Contractor's Name � ` se No./ G -�-3 2 3 Phoneq�6�- TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ - ' PUMP INSTALLATION ❑ SYSTEM REPAIR G}' - - OTHER'[] - DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION 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 Well Casing Cd'Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ EasternSurface Seal Installed by De y� Repair Work Done C1 Type of Pump H.P. / Y State Work Donee4�u !�-�1i 4 /Z+e Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth t 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.) r ; Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms r 4 Character of soil to a depth of 3 feet: Water table depth W SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line O LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line �'1 SEEPAGE PITS ❑ Depth Size - Number - - - - SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ r I hereby certify that I have prepared this application and that the work will be done in accordance- th San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. r Home owner or licensed agent's signature certifies the following: "I certify that in therformance-f 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 Cal'rfoirDia."Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for-whlch this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." J The applicant m all for all r inspections. Com ete�dra/wing or rse side. Signed X lMFitre: Date: ��TIVIENT USE ONLY c� (� Application AccJpted�'by ?+ .' Date �~ Z J Pit or Grout Inspection by Date Final Inspection by l/ Date 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 FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT"NO. + EH 1426(REV.10183) rtr S�Z+�/�� A.4.