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APPLICATION FOR PERMIT :1 �,& — !! SAN JOAQUIN LOCAL HEALTH DISTRICT. 1601 E. HAZELTON 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 sew a or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District.8436 a44 ql 1 TkorIntoV `RU• - Job Address i ce_ �nia rl► 11 ge, _ City s574V [s Lot Size PM q-(03-2711Owner's Name 5vu � Address r Phon�T� / Contractor L�l�IIyl�Llkt P{r I T 1'1• Address li r License No.e4_3Y`3 Phon l5 Z TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REP'JUR ❑ OTHER Pi— 3 DISTANCE TO NEAREST: SEPTIC TANK SEINER LINES DISPOSAL FLD. PROP. LINE 5 f• j FOUNDATION 1�1 AGRICULTURE WELL OTHER WELL_LZL• PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom El Manteca Dia, of Well Excavation Dia. of Well Casing ,rte , Gravel Pack ❑ Tracy Type of Casing. PV Specifications • pZD �''} ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout B �0�pprox. Deby-51e,-/a ❑ Irrigation Depth ❑ Eastern Surface Seal Installed Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') i Depth Filler Material iBeloh 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feetJ Installation will serve: Residence— Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: f Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLY. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & 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 ❑ 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 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 must call for I re uired inspections. Complete drawing on reverse side." Signed X � � x�_ Title: - �—�` Date: / OR DEPARTMENT USE ONLY Application Accepted by r— _ Date- __ -�G ! �-� Area Pit or Grout Ins Eon Date Final Inspection by Date Additional Com encs: Elk ❑ Stk 466-6781 ❑ L i 369-3621 ❑ Manteca 623-7104 ❑:Tracy 83 1 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 20095tk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED REC INFO CMH EIVED 9Y DATE PERMIT'NO. + EH f3-24(REV.x/65) - s EH 1426