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APPLICATION FOR PERMIT "or 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 se age or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. / �-{-- 2h / �� L4 (� Q �Z !/ .. Job Address 177 1 I ) � tt��1dJ`^-h_J City� 1 ot`SSimaize 1J� 64c. + PM Owner's Name Address 15 _ Phone '• ,Z� '' �-t�cense No. _�gS�Z g/ — J Contractor's Name Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ — — NA _ 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 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 V Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 r� TYPE OF SEPTtC WORK: NEW1NISTALLATIONREPAIR/ADDITION 1-1DESTRUCTION El (No septic system permitted if public sewer is . available within 200 feet.) Installation will serve: Residence! Commercial X_ Other ! Numper of living units: Number of bedrooms " 7 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ) Type/Mfg �� .� Capacity ZNo. Compartments 1. PKG. TREATMENT PLT. ❑ / Method of Disposal Distance to nearest: Well_ -' Foundation t— Property Line f __ N LEACHING LINE No. & Length of linesf lain _ Total length/size r,0�� FILTER BED ❑ Distance to nearest: Well Foundation_fCd� Property Line SEEPAGE PITS 'V Depth -5 Size 12/AM Number 2- c3- — SUMPS El Distance to nearest: Well Foundation t/� Property Line+ __ DISPOSAL PONDS ❑ 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. 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 o become sub)ect to workman's compensation laws of California."Contractors hiring or sub-contracting signature certifies the following: "I ce ' th in t e 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 must c for all equi inspections. Complete drawingon r erre side. Q Signed Title: � Date: 7- FOR FOR DEPARTMENT USE ONLY Application Accepted by 1 Date j [ Area vG` C Pit or Grout Inspection by Date Final Inspection by Date7—/ 11185 Additional Comments: 6781 El 369 3621 ❑ Manteca 7104 El 835 AStk 466 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazetton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. H 13-24(REV.10/83) 0�3 S'J -7- GLH 14-Z6 . G - `