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._ } APPLICATION FOR PERMIT SAN JOAO,UIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 Y :PERMIT EXPIRES 1 YEAR`FROM DATE ISSUED (Complete in Triplicate) work herein x cation is Application is hereby made to the San Joaquin Local Health District for a permit or to 1852 construct and/or install and the Ryles and Regulations of he San. This Joaquin made in compliance with San Joaquin County Ordinance No.549 } 9 ol Local Health District. City`r .�.� D�Lot Size .. i PM Jab Address _ / i5- YT�QQ�1� T �/,/Cly- R �f A4 Phone �'7- 7 r� Owner's Name ddress R Tom- 1 o I L4 4)X License No. Phone 3 1 mal a ,lontractor dress TYPE OF WELL/PUMP: NEW WELL ❑ 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 Dia. of Well Casing ❑ industrial ❑ Open Bottom Ll Manteca Dia. of Well Excavation Specifications 19 Domestic/Private C1 Gravel Pack ❑ Tracy Type of Casing F1 Public _. .,,��......, - ❑ Other- LJ Delta .Depth-of-Grout.Seal., - .Type of-Grout �. W ti ❑ Irrigation —Approx. Depth ❑ Eastern Surface Seal Installed by W I H p State Work Done Cp GX laST 6 Repair Work Done ❑ Type of Pump V W Well Destruction ❑ Well Diameter. Sealing Material (top 501 ; Depth Filler Material (Below 501 m TYPE OF SEPTIC WORK: NEW INSTALLATION LJ REPAIR/ADDITION ❑ DESTRUCTION ❑ availabllelwthin 200 feet.)- if public sewer is r i + Installation will serve: Residence Commercial_ Other i Number of living units: Number of bedrooms 9 Character of soil to a depth of 3 feet: I Water table depth f_; ... "ice SEPTIC TANK ❑ ,Type/Mfg CapacityNo. Compartments �- PKG. TREATMENT PLT. 11Method of Disposal Distance to nearest: Well Foundation � Property Line LEACHING LINE ❑ ,No. & Length of lines - — Total length/size + FILTER BED ❑ Distance ita nearest: Well Foundation Property Line } t ! SEEPAGE PITS O +Depth ISize Number l �.� SUMPS ❑ !Distance to nearest: Well -`Foundation; Property Line f ' DISPOSAL PONDS ❑ f ` 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 ork 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 i 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." 1 114 The applicant f all r it inspections. Complete drawing on rev rse s1 Title: Date: f Signed R DEPARTMENT USE ONLY-` f _ rw,,.• .� .;'� .�w Date.,,....,.,-- -- � - �� Area Application Accepted by4 i T Final Inspec57 tion by Date l Pit or Grout Inspection by Date , Additional Comments: I ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 f Applicant- Return all copies toi Environmental Health Permit/Smices 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 _ FEE' CK# RECEIVED 8Y DATE PERMIT"NO. INFO AMOUNT DUE_ AMOUNT REMITTED CASH +EH 13-24(REV.I/85) EH 1428