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i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 ,. '"PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is heieby•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 Rules and Regulations of the San Joaquin Local Health District. Job Address S�15t? - 1_411...W:ter R City Lot Size PM Owner's Name'Armor !j!4 Address -+ C0V Q?Cc-Phone I . t �' rC ev Address 76 10 C7 License No. 3��-�-�� Phone Contractor 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, .,r. TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. ofV1(eell Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specificati�Ans ❑ Public } " ❑ Other ❑ Delta Depth of Grout Seal Type of Grout i 11 Irrigation, —.-Approx.-Depth'. 4 I Eastern Surface Seal Installed by 'Repair-Work DoneL.J ' Type of Pump H.P. State'Work Done _ Y Well destruction -;i ❑ Well Diameter- - Sealing'Material (top 50') 1 .Depth Filler Material (Below 50') ` 04 TYPE OF SEPTIC WORK: NEW INSTALLATION 1'1,_R_ ITION I I DESTRUCTION f I (No septic system permitted if public sewer is f F�� available within 200 feet.) Installation wills e: Residence_ Commercial Y Other Number of living units:' . Number of bedrooms Character of soil 10 a depth of"3'feet: ij2� Water table depth t7 ` SEPTIC TANK ❑ "Type/Mfg Capacity No. Compartments f PKG. TREATMENT PLT. ❑€ .Method of Disposal Distance to nearest: Well Foundation Property Line v LEACHING LINE Lk—No. & Length of lines Y Total length/size if 04C FILTER BED ❑ Distance to nearest: " Well Foundation / f Property Line SEEPAGE PITS I 1 Depth '$ize /D Nurriber SUMPS Lz} Distance to nearest: WeII, I1- Foundation Property Line� ' i DISPOSAL PONDS ❑ 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. f.. 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." T The applicant must all for all required inspections. Complete drawing on reverse sine. e Signed X Title: Date: -FOR DEPARTM T USE ONLY Applica n Accepted by Date .Area rou I Cvon by Date r / Final Inspection by Date Additional Comments: ❑ Silk 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 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY 1 DATE PERMIT'NO. + EH 14.26 EV-1/K5) l�"/1A4 Ogrs