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V - - — A10 APPLICATION FOR PERMIT `//: SAN JOAQUIN LOCAL HEAE TH DISTRICT � F 1601 E. HAZELTON AVE., STOCKTON, CA �:�f jV �� -17 Telephone (209) 466-6781 ✓ �'_. '',PERMIT EXPIRES 1 YEAR FROM 'DATE ISSUED �9�T�PCi 9de v (Complete in Triplicate) Application is hereby made to the San J ;11Abed.Local Health District for a permit to construct and/or install the work herein described, Th Local Health District. fhation 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 an Jo f�� Job Address �, 'r Lot Size 11Cd —14—Sw x370 1 P' te" C Owner's Name Address f T 0 Q e a Phone 315 o2 P40 Contractor's Name License No. Ph one TYPE OF WELL/PUMP: NkW WELL WELL REPLACEMENT ElDESTRUCTION C1 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANKS WO • SEWER LINES DISPOSAL FLD. PROP. LINE � FOU NDATION ' ' - -AGRICULTURE-WELL`'' OTHER WELL'S — PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial El Open Bottom 11 Manteca Dia. of Well Excavation Dia. of Well Casing -j XDomestic/Private Gravel Pack " XTracy Type of Casing 096 Specifications ❑ Public ❑ Other C7 Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by . Repair Work Done ❑ Type of Pump'4 H.P. State Work Done Well Destruction ❑ Well Diameter; Sealing Material (top 501 Depth I Filler Materfal (Below 50') Ik TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ {Na 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 Ca act P ty No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line r rF � LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS C1 Distance to nearest: Well Foundation Property-,Lfne,. DISPOSAL PONDS L2 ., _ -. — -�- -- — 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 ust call for all req d inspections. Corn7 lets drawing on reverse si Signed D ' Title: �^ g Da R EPART _ENT USE ONLY Application Accepted by Date )` U Area Pk or Grout Inspection by 4VDate r. Final Inspection by Date t 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 K INFO RECEIVED BY DATE PERMIT NO. + EH 13-24IgEV.10A83} EH 3428