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APPLICATION.FOR PERMIT SAN JOAaUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE.,,STOCKTON, CA 'Telephone 12091 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED •.� a ,�,..;. .t•vet .:. . �!�. y,.� ; (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 Rules and Regulations of the San Joaquin }r Local Health District: - *� r 1tra,a ` •, i. : ' Job Address City Lot Size`s �� PM + r OWner's Name Address a 1 Al. J7 UT .7(7 a4n�4hone _ Contract Gr. Address PO ' a-�C��? O� `c� License No3-?g as& Phone,?&9 16S TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ + -PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ �r DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION' AGRICULTURE WELL OTHER WELL PITS/SUMPS A� F INTENDED USE 'TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private D Gravel Pack ❑ Tracy Type of Casing Specifications + ❑ Public ` ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation L---Approx. Depth ❑ Eastern Surface,Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ } Well Destruction ❑ Well Diameter Sealing Material (top 50') }�! i Depth Filler Material (Below 50') }J TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ PAIR ADDITION FT DESTRUCTION ❑ (No septic system permitted if public sewer is I available within 200 feet.) Installation will serve: Residence v Commercial,'Other Number of living units: Number of 44rooms I i UUU Character of soil to a depth of 3 feet:'J Water table depth SEPTIC TANK ❑. Type/Mfg. Capacity No. Compartments PKG. TREATMENT PLT_ ❑ Method of Disposal Distance to nearest: Well foundation Property Line i LEACHING LINE LK No. &'Length of lines �� Total length, X FILTER BED: ❑ Distance to nearest: Well= Foundationf G� Property Line' .� y ( SEEPAGE PITS �Depth tit, ; Size Number SUMPS `❑" Distance to nearest: Well l/�f�` Foundation 1/C%� Property Line_ Y DISPOSAL PONDS ❑ I hereby certify that l 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., fi 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, 1 shall not ; employ.any person in such manner as to become subject to workman:s compensation laws of T_ ii 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, st call'for I required inspections. Complete drawing on reverse si e. i t rs r k. Signed s F Title: Date:_(,— l.p I { FOR DEPARTMENT USE ONLY I. r `--- �Date'v i Area. >> Xation Accepted b + ,•�� ' 1—� _ / � 4 Grout Inspection by Date - ~~Final Inspection by fDate Additional Comments: ❑ Stk 44-6781 ❑ Lodi 369-3621 El Manteca 823-7104 •❑ Tracy 835-6385 Applicant- Return all copies to: Envirorimental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201rr / rr FEE INFO AMOUNT DUE " AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. r it - ♦! + EH1324(REV.i/n'SY ,per _Ire 3'-io f EH 14-26