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51 APPLICATION FOR PERMIT { SAN JOAQUIN LOCAL HEALTH DISTRICT SEP 10 1601 E. HAZEL T ON AVE., STOCKTON, CA � 4 Telephone (209) 466-6781 SAN JOAQUIN LOCAL iPERMIT EXPIRES 1 YEAR FROM DATE ISSUED HEALTH DISTRICT I (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 i Local Health District. ' /� Job Addresss�°�3 HI�� g g7- wiz/L � City4)5OdFC TO t4ot Size PM R _ ��JST/ilrkfO / Z/.2o ►A/iAedx x� � Phone Owner's Name �� 4A / Address rf Contractor's Nam N r 7E �L�Ptense No. / l+ Phone d TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION �sY,�T )(96AA-q CWFAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES`++`"`[[WF DIS_POS_AL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE_OF-WELL—P_ROBLEM,ARE, _I 019STRl1CTION SPECIFICATIONS _ter ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1^ ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Typeof Grout ❑ Irrigation ---Approx. Depth�e ❑�Eastern Surface Seal Installed,by, Repair Work Done ❑ Type of Pump' 1: Sd 2_ H.P. �-�^�^^ "^Sta ork Done JCl 1 b +` Well Destruction ❑ Well Diameter? Sealing Material (top 501 +-,OAAn -.3VJ1TN Ua „ Depth Filler Material ABelok 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ iNo septic-system permitted if public sewer is { available witKin 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 r SEPTIC TANK ❑ Type/Mfg ^'� Capacity 'z _,,,,No. Compartments I� PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line E i LEACHING LINE ❑ No. & Length of lines Total lengtWsize f FILTER BED ❑ Distance to+nearest:r Well Foundation Property Line ,! SEEPAGE PITS ❑ Depth _ Size Number / `"—" SUMP$ — ❑! Distance to nearest:' — Well "�--``— -- � -^•- '�'°"� �"""` "�` Foundatioh """'PPopert}rtine�� -- DISPOSAL PONDS ❑ I _ 4 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 e 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 all required inspections. Complete drawing on reverse side. Signed X Title: Date: FOR DEPARTMENT USE ONLY s Application Accepted by ,,0< Date Area 0 1 G IIU Pit or Grout Inspection by Dae Final Inspection by Date 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 S . FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVER BY DATE PERMIT N0. + EH 1324 MEV.10/831 �•'�-S p p ` EH 1418 II l