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DR APPLICATION FOR PERMIT AUG 2 11984 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA SAN JOAQUIN LOCAL Telephone (209) 456-6781 HEALTH DISTRICT 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. THS application is made in compliance with San Joaquin Courcy Ordinance No.549 for sewage or No:1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. i,. Job Address Ci Size PM Owner's Name -� rsss fd rZ - C Phone Contractor's Name ZA cerise No./-CSJ 23 / Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION El PUMP INSTALLATION F� SYSTEM REPAIR 0' _OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS . ❑ Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Dia.-of-Wel!-Casing L-4Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing ' Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation _�_Approx. Dept ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done �-� Well Destruction ❑ Well Diameter Sealing Material {top 501 Depth Filler Material (Below 501 Y TYPE OF SEPTIC WORK: NEW INSTACLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION 0-(Nb septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other r Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/MfgCapacity. No, Compartments PKG. TREATMENT'PLT. ❑ ' Y Method of Disposal Distance to nearest:- Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance tojnearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth 1I Size Number s SUMPS ❑ Distance to'nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I 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 j rules and regulations of the San Joaquin Local Health District. 1 Home owner or licensed agent's signature.cert'rfies'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 c or all r rN inspections(5Wplete drawing o reverse side. — Signed tle: Date: 17F� FOR DEPARTMENT USE ONLY Application Accepted by (N Date _ Area Pit or Grout Inspection by I Date Final Inspection by Date 11;_ y Additional Comments: ❑ Stk 466-6781 ❑ Lodi 3W3621 Q 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 I FEE INFO AMOUNT DUE t AMOUNT REMITTED CASH RECEIVED BY DATE- PERMIY'NO, + EH 13.24(REV.10183, EH 14-26 10