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APPLICATION FOR PERMIT A i R . {r, %*g SAN JOAQUIN LOCA0HEALTH DISTRICT 1601 E. HAZELTON ON AVE., STOCKTON, CA ' Teleptrone (209)'466-6781 } PERMIT EXPIRES 'I .YEAWFROM 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 Ryles and Regulations of the San Joaquin .Local Health District'.{I (Z`"7 ao '.Lc Cs Vs*t`,�j 7 ��rtiEi�� r f�IG /..-,.P+li i! i�'�' .�, G'"�[J —0-70 Job Address, S {r .I �4'r"� c� JG�f.J�^Ga C� /� � �LqI, F L) I R.p tY I Lot Size PM �� -. $Y.`+ ., � �� '�. •.E.-�r�� $"i..,1` iii}�' „� °�.; _ .- .. y. 1 I Owner's)Name V � >� Address -121 UZ �� ' 1�� :�r a l��Gi Phone 6 11^ Contractor ,ei Address License No. Phone i TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT,❑ 4. DESTRUCTION ❑ PUMP 1NSTALLATIONJ4 SYSTEM REPAIR,E) „k OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL t PITS/SUMPS 1 INTENDED USE TYPE OF WELL' PROBLEM AR EA,—CONSTRUCTION SPECIFICATIONS- - ❑ Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing -� >(Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications �} ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout J ❑ Irrigation _---Approx. Dept^ ❑ Ea rn Surface Seal Installed by Q• l Repair Work Done IJ Type of Pump�' ►� H.P. 2 State Work Done Q Well Destruction ❑ Well Diameter Sealing Material (top 50') _ : ++ ?; Depth Filler Material (Below 50'1 ' }n TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑t DESTRUCTION ❑ (No septic system permitted if public sewer is J' available within 200 feet.I Installation will serve: Residence_. Commercial_ Other- t Ft. 1 Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: ` - t Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. CompartmentsE PKG. TREATMENT PLT. ❑ Method of Disposal } Distance to nearest: Well Foundation- Property Line LEACHING LINE ❑ No. & Length of lines 9 °`� Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth `' 4w Size; t x Number SUMPS ❑ Distance to nearest: Well ��' Foundation Property Line DISPOSAL PONDS ❑ q 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 regulationsV'the San.Joaquin Local Health District. T - Home owner or licensed agent's signature certifies the following: "I certify hat 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'iri 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 applican t call r all egu- inspections. Complete drawing on revere side. Signed Title:_ ��_T/h o Date: —2 S' d-6 FOR DEPARTMENT USE ONLY ` Application Accepted by Date I/-2-5— Area / ,Pit or Grout Inspection by Date Final Inspection by Date if Additional Comments: ❑ Stk 466-6761 ❑ Lodi 369-3621 O 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 y FEE AMOUNT'DUE AMOUNT REMITTED RECEIVED BY PATE PERMIT"N0. INFO + EH13241AEV.t/65) SA�a . 14�b EH 1426