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j APPLICATION-FOR PERMIT 4— SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE.,.STOCKTON, CA Telephone (209) 466-6781 L; PERMIT EXPIRES"1 YEAR FROM DATE ISSUED % hw (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: 1 4U { Job Address �� City Lot Size PM Owner's Name ore A JG eo n f T&64A ress Phone # Contractor Address z` _:.;��J1 rC� /2icense No. Phone 1 TYPE OF WELL/PUMP: NEW WELL ❑;__- F -WELL REPLACEMENT ❑ ' DESTRUCTION ❑ I PUMP INSTALLATION JO )ZEAkR4E��//77""��YSTEM REPAIR ❑ OTHER 1-1DISTANCE TO NEAREST: SEPTIC TANK SEdMIXES DISPOSAL FLD. PROP. LINE _ .-FOUNDATION- -- ."AGRICULTURE-WELL. ---,-OTHER_WELL PITS LS U10PS_1–_- INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑Industrial ❑ Open Bottom - ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑`Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ----Approx. Depth ❑ Eastern Surface Seal Installed by j Repair Work Done ❑ Type of Pump H.P. -3 State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') _Se1J., u�/�'h� /LSF At./ Depth l Filler Material (Below 50') i TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ iNo 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 G SEPTIC TANK ❑ Type/Mfg l Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal j Distance to nearest: Well Foundation (Property Line "."��l 6 LEACHING LINE LI No. & Length of lines --.Total length size FILTER BED ❑ Distance to nearest: Well i Foundation 1�-If"Property Line SEEPAGE PITS 11Depth Size --�^.ry'a- Number I SUMPS ❑. Distance to nearest: Well Foundation -��-• perty DISPOSAL PONDS ❑ �. r,-v,\+ P11 I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state Jews, and i 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,X.shall not employ any person in such manner as to become subject to workman's compensation lawsofCalifornia." 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." J The applicant must c Il or II required inspections. Complete drawing on reverse Signed X `Title: Date: s-zLd Rae rn FOR DEPARTMENT USE ONLYele Application Accepted by Date Area I Pit or Grout inspection by Date Final Inspection by l Q aOlt y : tCU Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy. 835-6385 > F Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 rr1 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT a INFO CASH + EH 13-241REV.1/85) EH 14-28