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APPLICATION FOR PERMIT 4 SAN JOAQUIN LOCAL HEALTH DISTRICT "s 1601 E. HAZEL i ON AVE., STOCKTON, CA Telephone (209) 466-6781 { PERMIT EXPIRES 7-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 j 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.' . M, ',t# , Job Address N � r.. City Lot Size PM Owner's Name Q ddress hone r IZ // . 7� y77--2- Q/ i Contractor Address .� L icense No.__g�`/�Oif J Phone TYPE OF WELL/PUMP: NEW WEL' WELL REPLACEMENT: DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 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 Excavationr� Dia. of Well Casing ❑ Domestic/Private )(Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout EJ --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. `�• State Work Done Well Destruction El Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEIN 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 ` Character of soil to a depth of 3 feet: ' Water table depth SEPTIC TANK ❑ Type/Mfg't Capacity i No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line r LEACHING LINE ❑ No. & Length of lines \� Total length/size i FILTER BED (Distance to nearest: Well Foundation Property Line t SEEPAGE PITS ❑ Depth ! -Size Number SUMPS Cl MPS _ LJ_ Distance toynearest; Welt Foundation Property Line DISPOSAL PONDS _ - — —. _-� --thereby 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, 1 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 ust call for all re uire spections. Comp/ to drawing on reverse sL-0 Signed isle: c� Date: i y{� B 713 R DEPAR ENT USE ONLY 'Application Accepted by 7-2f �s {7 t Date Area—_-� Pit or Grout Inspection by ! Date Final In spection by Date Additional Comments: awlf * — ,/ �_ 4 ;, > El5tk 466-6781 13 Lodi 369-36211 ❑ Manteca 823-7104 V ❑ Tracy 83 _ i� Applicant- Return all copies to:.Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 s FEE K INFO AMOUNT DUE i AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'N0. + EH 1324(REV.5/95) EH 1 ��` 426 ,