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r - APPLICATION FOR PERMIT ;i `SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.'HAZELTON AVE:, STOCKTON, CA Telephone (209) 466-6781 I 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 sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. , Job Address City SjWorrdl- - Lot-Size PM i Owners Name _ GP.��,'n /� �(rire to Address 1 y0 6J-P- At&�T Plion,-r 11-3 Contractor � -U�tP�Ort/}7/ire Address /i130 E[.brr.4 �a License No. O Z Phone y/ G �- TYPE OF WELL/PUMP: NEW WELL R) WELL REPLACEMENT ❑ DESTRUCTION ❑ " PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE V FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS' ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation f8" Dia. of Well Casing o?n 2 Ber�estiefRxivete X Gravel Pack El Tracy Type of Casing -S-4 1'0 PICC Specifications ❑ Public 19of' �� wdf ❑ Other ❑ Delta Depth of Grout Seal ?O' Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done r Well Destruction ❑ Well Diameter Sealing Material {top 501 Depth pot Filler Material (Below 501 { YPE OF SEPTIC WORK: NEW INSTALLATION ❑, REPAIR/ADDITION ❑ DESTRUCTION ❑ {No septic system permitted if public sewer is ' available within 200 feet.) Installatr 'I serve: Residence Commercial_ Other Number of living un Number of bedrooms Character of soil to a depth o t: able depth i SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments f PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well ation Property Line LEACHING LINE ❑ No. & Length of lines Total size FILTER BED ❑ Distance t rest: Well Foundation Property Lr I SEEPAGE PITS ❑ Depth Size Number S ❑ Distance to nearest: Well Foundation- Property Line SUMPS PONDS ❑ 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."Contractors 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 all requir inspections. Complete drawing on reverse side.'. �I Signed Title:�e�r 6r-awisr/ /Ea 4��5Y15.q Date: lf/_* 2 FOR DEPARTMENT USE ONLY Application Accepted by �L Date �— Area Pit or Grout inspection by Dat6 fid _ - Final Inspection by F'F—CA-.L+ J-p_,,�n Date j 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.Q. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTEDRECEIVED BY DATE PERMIT'NO. INFO � � C-yASH / I + EH 14-261REV.1/85l � , �V / e il'_/O� ��