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it i II APPLICATION FOR PERMIT q SAN JOAQUIN LOCAL HEALTH DISTRICT 160?'E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES-1 YEAR FROM DATE ISSUED. . (Complete in,Triplicatel. ,. Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.'Th+s application is made in compliance with San Joaquin County Ordinance No.54.9 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. s yrtz" 'J .T7"H, y• .R. Is r tk Job Address vC O Ot/ F 10� . �F�1GL�1 + City ✓ `Lot Size PM - -Owner's Name l GIL S0. UC e Address ,�' �O In . i ce phor. (D.Z�-1 Zd C&tractor }' Address License No. _ Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION �. PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEINER LINES _ DISPOSAL FLD. PROP_.-LINE`. . - `�� `� ��FOl1F1QA710N AGRICULTURE WELL�� _ OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA - CONSTRUCTION'SPECIFICATIONS r 1',Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation pia. of Well Casing UrDomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ' ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout __ ❑ Irrigation -LApprox. Depth ❑.Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done I Well Destruction )90. Well Diameter Sealing Material (top 501 II _ Depth Filler Material(Below 501 - If PE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION LL DESTRUCTION ❑ (No septic system permitted if public sewer is p available within 200 feet) Installation erve, Residence— Commercial_ Other Number of living units. Number of bedrooms Character of soil to a deptWof 3 e Water table depth SEPTIC TANK ❑ Type/Mfg _. Capacity. No. Compartments PKG. TREATMENT PLT. ❑ �j Method of Disposal I 1 Distance to nearest: Well dation Property Line r LEACHING LINE ❑ No-&Length of lines ngth/size FILTER BED ❑ 'Distance to nearest: Well Founclation Pro a Line • r li SEEPAGE PITS` ❑ ?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 San Joaquin county ordinances, state laws, rules and regulations of the San Joaquin Local-Health District. f 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,1 shall employ persons subject to workman's compensa- tion laws of California." ��. The'applicant must Cfor all'r quired in tions: Complete draw- on reverse side. �� 7 d Sig X L G� Title: (�'t.0 rt�[%�r ..... Date: L -FOR DEPARTMENT E ONLY L Application Accepted by :i Date --4 Area Pk or Grout Inspection by Date_ Final Inspection by Date • %�r 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 INFO AMOUNT:OU£ AMOUNT REMITTED 7C�K-" RECEIVED BY DATE PERMIT'NO. + EH 13241REV."r!nc) j' EH 11-28 4' !