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d APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE.T ON AVE., STOCKTON, CA Telephone (209) 466-6781 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.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. rri Job Address City Lot Size Owner's Name Address Phone 7 7 QL _y f 41 -%8ar. , Ccs , 4 Contractor's Name vizrV I ri License No. - Phone 7 TYPE OF WELL/PUMP: NEW WELL-W WELL REPLACEMENT ❑ DESTRUCTION ❑ ✓ PUMP INSTALLATION ► SYSTEM REPAIR❑ . OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK .SEWER LINES r :DISPOSAL-FLD. 0!PROP. LINE FOUNDATION SD f AGRICULTURE WELL hQROTHEkVELLYI� PITS/S � LIMPS L4 t - INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial )COpen Bottom ❑ Manteca Dia. of Well Excavation 1 Dia. of Well Casing #` .Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_._�_�� 1 Specifications. ❑ Public ❑ Othar ❑ Delta Depth of Grout Seal f Type of/Grout r ° a�l I f K W ❑ lrrigatiorr �Approx. Depth ❑ Eastern Surface Seal Installed by , Repair Work Done F1 Typo of Pump $r7 H.P. _ State Work Done s :Well Destruction ❑ Well Diameter Sealing Material (top 50') 1 Depth J Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is �p1 i n available within 200 fee0 ' Installation will serve: Residence_ Commercial_ Other 1 Number of living units: { Water table depth Number of bedrooms �? .Character of soil to a depth of 3 feet: P SEPTIC TANK ❑ Type/Mfg �-��-Capacity No. Compartments PKG. TREATMENT PLT. El i t 'M. ethod of Disposal Distance to nearest: Weill Foundation Property Line { ' r LEACHING LINE ❑ No. & Length of Lines Total length/size f x FILTER BED ❑ Distance to nearest: Well Foundation Property line x s G 1 SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ V 1:_.M4-.,.0 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 regulations of the San Joaquin Local Health District. I j Homeowner 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 #I employ any person in such manner as to become subject to workman's compensation laws of California."Contractoes 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." *c. t The applicant m t call for all required inspectio{ts. Complete drawing on'reverse side. 5 F Signed Title: C Date: -3 FORTMENT USE ONLY Application Accepted by Date Area glePito Gro Inspection by Date "' Final Inspection by { eo i Additional Comments: ❑ Stk 466-6781 Lodi 369-3621 , ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all o ies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 1 > FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. f ��U 3l3 t 2S 1 i- + EH 13-24IREV.10/93) 1 G \ EH 14.28 fff J