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I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA A Telephone (209) 466-6781 i PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby Ihade 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 wifh 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. f r9i[gf / !lr Q 'T City + Lot Size 140 X /60 PM Job Address G f / i � ��P Address c5�6U� s! Phone S) 'Z!6 3 Owner's Name it Contractor GRd Address �9D PIKS �� iL"�nse No. 3� Phone TYPE OF WELL/PUMP: NEW WELL 1Z, WELL REPLACEMENT ❑ DESTRUCTION ❑ ;II PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 11 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE ! TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS laid Dia. of Well Casin ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Weil Casing (�za OV—Let ❑ Domestic/Private Gravel Pack ❑ Tracy Type of Casing Specifications �I (O ET r•n 11'11 T of Gr ut ��✓% ❑ Public PtiQ�i �❑ Other 1-1 Delta Depth of Grout Seal Type ❑ Ir i o WELL ;OMpprox: Depth ❑ Eastern Surface Seal Installed by! 'PF1L x brdoa% State Work Done Repair ork one O Type of Pump H. Well Destruction El Well Diameter Sealing Material (top 501 �j Depth Filler Material (Below 501 i TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is I, available within 200 feet.) c Installation will serye: Residence— Commercial — Other Number of living units: Number of bedrooms Character of soil t a depth of 3 feet: Water table depth SEPTIC TANK II ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line I LEACHING LINE ;y F-1No. & Length of lines Total length/size FILTER BED �,` ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS `` ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS"II ❑ I hereby certify that II have prepared re ared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and 1 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."Contractors hiring or subcontracting 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 mus ci"all for I req 'ns%c tion Complete drawing on reverse side. J Signed c , Title: Date: r ? y US7EN Y Application Accepted b Date Area € pit or Grout In ti y Date Final Inspection by Date iiZ:Z�g6; Additional Comments ' ❑ Stk 466.6781 "Il ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8354305 Applicant- Return 611 copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 u FEE' AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMI-r NO. INFO'. + EH 13-241REV.1/85] 1' `�S'Crt1� - `- Oma•"' G � EH W28