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APPLICATION FOR PERMIT Q (��' aZ� SAN JOAQUIN .LOCAL HEALTH DISTRICT 44_" 1601 E. HAZE.TON AVE., STOCKTON, CA 1 -_ Telephone (209) 466-6781 5' �, PERMIT EXPIRES 1 YEAR FROM DATE ISSUED H� J040IJ % (Complete in Triplicate) r/� ' to, Application is hereby made to the San Joaquin total Health District for a permit to construct and/or install the work herein descri�Ms�'application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1852 for well/pump and the Rules and Regulations o the San Joaquin Local Health District. Job Address JWu �1.-, City�)4�44J Lot Size PM Owners Name T1 M �J I7�I � 1��Z Address m fg 1�1� Phone � � 9• i r ��++11 - 20-7 Contractor's Name r c.� '1J �L7Z(icense No. V Phone 09 I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 04 OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE r ,.s 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 Jif Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications r ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done OZ Type of Pump H.P. 1_ State Work Done 912944 Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material IBelow 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 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments I> i PKG. TREATMENT PLT. ❑ Method of Disposal {{{y I Distance to nearest: Well Foundation Property Line i LEACHING LINE ❑ No. & Length of lines Total length/size i FILTER BED ❑ Distance to nearest: Well Foundation Property Line i i SEEPAGE PITS ❑ Depth Size Number i SUMPS ❑ Distance to nearest: Well Foundation Property Line y DISPOSAL PONDS____._j-J.._ � _-a Y_ _ �_. ., ...... 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 Acall for all requir ns ons. Complete drawing on reverse side. / Signed Title: Date:�lew-C FOR EPARTMENT USE ONLY / Application Accepted by Date — Area 0[� ' 2 Pit or Grout Inspection by Date Final Inspection by 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 AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. INFO1 CASH + EH 13-24(REV.10/83) FZSS- .. EH 14-26 11 Q� �� i-ll�s