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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (200) 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 wo .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 Local Health District. ; Job Address 46®.3 G. W ANSA,&&&rw A) ,S"T City � Lot Size '7rI O PM '%A-P"� Phone 7a S« Owner's Name t�-�FrS Address Contractor 12L:�CW t?. C -W010 2) Address A). j_/LL/AA/ 14&License7No:��Xe7L Phone bs TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ '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 iTYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI DNS ❑ Industrial ❑ Open Bottom;: ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑Tracy Type of Casing Specifications 1 ❑ Public ❑ Other s O Delta Depth of Grout Seal Type of Grout ❑ Irrigation +L--Approx..Depth ❑ Eastern Surface Seal Installed by r/ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter —Sealing MateHal-ftop 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK:1 NEW INSTALLATION ❑ REPAIR/ADDITION ❑' DESTRUCTION (No septic system permitted if public sewer is I . � available within 200 feet.) 0 Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms r ; Character of soil to a depth of 3 feet: Water table depth fiR SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments a PKG. TREATMENT PLT. ❑ 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 t SEEPAGE PITS ❑ Depth Size Number 1 SUMPS p 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. J Home owner or licensed adent'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 f certifies the following: "1'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." T - The applicant tmmust call for all required required inspections mplete drawing on reverse side, ~ Signed X.��1�1--�1r �f "I Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by nate Pit or Grout Inspectio b4_ Date Final Inspection by ` Dal Additional Comments: .S`.0�, �. L"lt"t.k rf ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 V ❑ Tracy 835 638 11r Applicant - Return all c pies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 7Z5 I V-A INFO AMOUNT DUE AMOUNT REMITTEDCX5RECEIVED BY DATE PERMIT'NO. f + EH 13.24(REV.1/85) t"" �1 EH 1426 9-7