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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 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 made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the RLjles and Regulations of the San Joaquin Local Health District. 1 Job Address City Lot Size A-A16 PM Owner's Name 041/S�A&, U.SSWAddress -34 ��b�_A�P PhoneOV—=Z?z� VW Contractor Address c2120 rt�/LCA d/W-License No.�Sr/�Bl Phone TYPE OF WELL/PUMP: NEW WELL j0WELL�REPLACEMENT El DESTRUCTION ❑ MP _,. . INSTALLATION J� _ SYSTEM REPAIR El _ _ OTHER-11 DISTANCE TO NEAREST: SEPTIC TANK ;Ib4� wSE1N bR LINES - I=f= DISPOSAL FSPROP. LINE f; }:T./ FOUNDATION AGRICULTURE WELL D, .OTHER WEL `+' PITS/SUMPS INTENDED USI=_ l TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ' �pomestic/Prnrate �jGravel Pack El Tracy Type of Casing T >r[ Specifications j ❑`P.ublic t7 Other ❑ Delta Depth of Grout Seal \ Type of Grout ❑ Irrigation ' Z22Approx. Depth ❑ Eastern Surface Seal Installed by ". Repair Work.Done ❑ Type of Pump ,$11_[ H.P, Z State Work Done lhls �q,(�, N�&622,yejr I Well Destruction ❑ Well Diameter Sealing Material (top 501 + Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ .REPAIR/ADDITION ❑ DESTRUCTION'❑ (No septic system permitted if public sewer is ; available within 200 feet.) i! Installation wi41 serve: Residence_ Commercial— Other Number of living units: Number of bedrooms l:. i Character of soilto a dep—th of 3 feet: Water table depth !SEPttC-T1AN1P-*4 ❑ Type/Mfg Capacity No. Compartments Y PKe REATMEN_T PLT. ❑ i Method of Disposal y m r r Distance to nearest: Well Foundation Property Line j LEACMING LINE ❑ No. & Length of lines t Total length/size FILTER' BED ❑ Distance to nearest: Well ( Foundation Property Line 0 r r i ---SEEPAbE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line y 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, abd rules and regulations of the San Joaquin Local Health District. I 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- ' t tion laws of California." The applicant m call fo all r red inspections. Complete drawing on reverse 'de. I Signed X �/ _ Title: Date: + FOR DEPARTMENT USE ONLY Application Accepted by �� Date Area j Pit or Grout Inspection hy.� Date `7 Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 359-3621 ❑ 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 95201FEE I! INFO AMOUNT DUE AMOUNT REMITTED GASH RECEIVED BY DATE PERMIT'NO. +EH 13-24 ME �' / '93 EH 14-26 C]R? 7 S —g �C�