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it APPLICATION,FOR,PERMIT SAN JOAOUIN.LOCAL HEALTH DISTRICT 1601 E, HAZEL T ON AVE., STOCKTON, CA Telephone {209} 466-6781 ' �! PERMIT EXPIRES 1 YEAR FROM DATE ISSUED .I (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 made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 far well/pump and the Rules and Regulations of the San Joaquin Local Health District. _ L ors- zoo S.7 Job Address Qlty�.� ;V '1/11 i- SI'wDDdf3RldQt' �R �h6CityWob� LotSize -s" 1y1p� PM ..-. Owner's Name 1]! I/ 1 >I UC Ub�p rXllw AGI Address -)7S5_ S 1 Phone C?51S787 5 9<f S88 Contractor's Name 19G License No. 3 S G;'.2 1,3 Phone' / 7 I TYPE OF WELL/PUMP: NEW WELL C9 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE n� r FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ,r ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Ll ❑ Domestic/Private 0? Gravel Pack"� " ❑ Tracy Type of Casing. 57kZt- Specifications' 4 r ` 19 Public ❑ Other ❑ Delta Depth of Grout Seal _ c�d Type of Grout L3 ❑ Irrigation ?=�Approx. Depth ❑ Eastern Surface Seal Installed by I iF iva s DR 1 I 11'1v O Repair Work Done ❑ Type''of Pump H.P. State Work Done T, Well Destruction ❑ Well Diameter Sealing Material (top 501 O Depth c5 Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ iNo septic system permitted if public sewer is l i available within 200 feet.) Installation will serve: I Residence— Commercial_ Other Number of living units: :. Number of bedrooms m r� Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg t 1 a, 1 Capacity No. Compartments I PKG. TREATMENT PLT i❑ Method of Disposal r g " F Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines ' Total length/size FILTER BED 1,110 Distance to nearest: Well Foundation Property Line SEEPAGE PITS iEl Depth Size r Number rt r SUMPS ,❑ Distance to nearest: Well a Foundation Property Line r DISPOSAL PONDS '❑ 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." ' ii l The applicant must call fo all required inspections. Complete drawing on reverse side. C Signed Title: � Date: ^�D FOR DEPARTMENT USE ONLY m Application Accepted by Date `s L � Areaif Pito spection by Date1; Final Inspection by Date � r 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.Q. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTEDw C 11 � RECEIVED BY.; C' DATE PERMIT"NO. + EH1 3-241REV.10/83) EH 1426 F i