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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 �. PERMIT EXPIRES TYEAR FROM DATE ISSUED {� (Complete in Triplicate) I4 Application is hereby made to the San Jdaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin C - my Ordinance No.549 for sewage or No. 1862 for welUpump and the Rules and Regulations of the San Joaquin Local Health District. Job Address / � W��//fit Cit Lot Size PM y Owner's Name Address ZelS-el//LL/T`L _ Phone rn m � zl7_y (ADI '� � �_1 Contractor �P Address __ License No. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ j 3 PUMP INSTALLATION STEM REPAIR ❑ OTHER ❑ 1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP]LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ;RQbomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ("l Public Cl Other 171 Delta Depth of Grout Seal Type of Grout I Irrigation _Approx.�Depth I I Eastern S�rf ee Seal Installed by r Repair Work Done ❑ Type of Pump H.P. -��:.,-_,._ State Work Done f.- � ..�/b057 J, Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material iBelow 50') jt TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION 1 I DESTRUCTION [ I (No septic system permitted if p`blic sewer available within 200 feet.) l Installation will serve: Residence_� Commercial-W___ Other I i (ir Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth ` SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments t*3 PKG. TREATMENT PLT. ❑ Method of Disposal. 4 I tw E Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size ; I FILTER BED ❑ Distance to nearest: Well Foundation aro'perty Line 11 - I� t � SEEPAGE PITS I I Depth Size Number i SUMPS L7 Distance to nearest:t-__Weil Foundation Property Line DISPOSAL PONDS L1 �k` � . 3\ �ik—A i � i 1-hereby-certify-that4-have•prepared-this.application-and-that_thework-will„be done_in.accordance with San Joaquin county_ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. s' 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 com�ensationJaws of California.” Contractor's hiring or sub-contracting signature certifies the following: "I certify .4 cj , 9 fd 9 g to y that in the performance of the work for which this permit is�ss'ued, i shall employ persons subject to workman's compensa- tion laws of Caiifo The a lica c re uir s. Complete l I 1 PP ete dtawin on rev rs side. _ Signed X title: )� Date: 1 F EPARTMENT USE ONL A f Application Accepted by ( Date Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: t ❑ Silk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazeiton:Ave., P.O. Box 2009, Stk., CA 95201FEE CK { INFO AMOUNT DUE '' AMOUNT REMITTED CASH RECEIVED BY DATE HERMIT'NO. r.EH 13-24(REV.1/95) EH 14-26 ✓ f • I I -!