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APPLICATION FOR PERMIT SAN JOAO.UINj LOCAL HEALTH DISTRICT i 1601 E. HAZE,TON AVE., STOCKTON, CA { Telephone 12091 466-6781 a PERMIT EXPIRES 1 YEAR FROM DATE ISSUED .Ii (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. 1562 for well/pump and the Ryles and Regulations of the San Joaquin Local Health District. Job Address City Lot Size PM v Owner's Name e a ss - Phone 't 14 Contractor Address ►+ l License Nope Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ s 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 `--TYPE-OF+WELD PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial �` ❑'Open Bottom ❑ Manteca 4 Dia. of Well Excavation Dia. of Well Casing ❑ Domesti&Private ❑"Gravel Pack { ❑ Tracy Type of Casing Specifications ElPublic ❑ Other i ❑ Delta } Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern t Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done ---• v�1 r Well Destruction ClWeli Diameter- '` Sealing Material {top 50'1 Depth y`.dN i �_ Filler Material (Below 501) 1 TYPE OF SEPTIC WORK: `NEW INSTArLATION ❑' REPAI ADDITIO DESTRUCTION'51iNo septic system permitted if public'sewer is� f, / It available within 200 feet.1 { Installation will serve: R�idence_ Comm`ercial_ Other ! wf� � .,t Number of living units: I :-. Number of bedr ms Character"nf soil to a depthof-$.-feet: _ Water table depth r SEPTIC TANK 'P,.Q -Type/Mfg P Capacity f No. Compartments PKG. TREAT-MENTI RUT 5 `•_ { Method of,Disposal j O~ " .�? — WellZF�o'u�i rnda{tion J I ter—Property-Line...`"'..'. �--.�" " egtTotal length/size - —"Y LEACHINGNEOLnh FILTER BED ❑ distance to nearest: Well, Foundation Property Line' 0k SEEPAGE PITS ❑ depth Size Number 3 SUMP-S__.,-❑_ _Distance,to-nearest:-.„_-_"Well foundation /O l� Property Line DISPOSAL PONDS ❑ I hereby certify fha't-i"have prepared this applicaiionland 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 bis;rict. _ _ 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 iri such':manner as t6.become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following:"I certify that rote performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa,- +.. taws-of California. c t sf � . +i t ! C 1 ' _ ion_l 'S The applicant st call all require ction omplete drawing on nnnrrreevverse side. c Signed Title: �/l Date: V FOR DEPARTMENT USE ONLY Application Accepted by aa Date 2 Area 1 Q Pit or Grout Inspection by + Date V� Final Inspection by V Date ! �J Additional Comments: Z,5tk 46&67$1 ❑ 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 CK RECEIVED BY DATE PERMIT'NO. + EH 13-241REV.1/85) � o o / / &S S57 A S-7 EH 1425