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• �ed4 APPLICATION FOR PERMIT %-V X 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 forsewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. �9,k-0 n Job Address, er-c ,� !^�� 11071 tL Citjm—� Lot Size PM i Owner's Name _>�[_ ` (o W LZ 1— c Address Phone i Contractor Pe-YC vol. Address 5) l!'-C/ License No. LZ Phone { TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO.I01Y PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL - PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS` ❑ Industrial ❑ Open Bottom ❑ Mdnteca Dia. of Well Excavatio L Dia. of Well Casing r C\ ? Domestic/Private (�f�6ravel Pack Tracy Type of Casing— Lqr Specifications L l� �S M Public n Other ❑ Delta Depth of Grout Seal ! Type of Grout I I Irrigation l577VApprox. Depth I i Eastern Surface Seal Installed by-.,Ccut)7 V } I Repair Work Done - ❑ Type of Pump H.P, State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') � k Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION I I DESTRUCTION ( I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other ` 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 PKG. TREATMENT PET. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line j LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size _ Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with $an Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. 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 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." The applicant st call fors uir ns 1c lions. Complete drawing on t arse side. Signed X Title: :�igJI Date: ?f i FOR DEPARTMENT USE ONLY Application Accepted by Date 'Area Pit or Grout Inspection by Date � Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ 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 i INFO AMOUNT DUE AMOUNT REMITTED CK 0 ASH RECEIVED BY /y DATE PERMIT NO. +.EH 13-241pEV.1/85) EH 14-28 k