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S APPLICATION FOR PERMIT SAN JOAQUIN 4 LOCAL HEALTH DISTRICT 1601 E. HAZEL-I ON AVE., STOCKTON, CA -Telephone (209) 466-6781 PERMIT EXPIRES I YEAR'FROM"DATE ISSUED'' m (Coplete in;Tripllckt ) . ^,[i a... sir t ..•,. + r....A�J�� .��C `�.:� 2 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 Ryles and Regulations of the San Joaquin Local Health District. ,f ' .:a.e. t_O r!- a Ml.s `JCl�cka.i Jab Address 520.3 U �f r-f 0� } R City Lot Size_ PM Owner's Name " "-Address '�O3 !.(I; hone $ VD 57 Contractor ,5• Address di�ticense Na. Phone TYPE OF WELL/PUMP: : NEW WELL E] WELL REPLACEMENT DESTRUCTION 1-1 PUMP INSTALLATION ❑� SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK Z:YjQ SEWER LINES - DISPOSAL FLD. PROP. LINE j •A FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA -CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom Manteca Dia. of Well Excavation Dia. of,Well Casing .Domestic/Private XGraval Pack ❑ Tracy Type of Casing to.V1121 Specifications E ❑ Public ❑ Other ❑ Delta --Depth of Grout Seal Type of Grout ' f r ❑ Irrigation --approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done I �eU Destruction ❑ Well Diameter �.".. Sealing Material (top 501 �vOl �I Uj(e}►11Q Depth Filler Material (Below 50') tTYP"F SEPTI" CORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is L! 4t"__5 _ available within 200 feet.) a(�InstallAiion will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments 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 SEEPAGE PITS ❑ Depth "' '" Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ -I hereby certify that./ have.prepared this application and that the work will be done in.accordance with San Joaquin-county.-ordinances,.state.•Iaws, 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,1 shall employ persons subject to workman's compensa- tion laws of Califo nia." l The applic nt m t call for all req fired i ctions. Comple drawing on reverse side. 1 y Signed Title: . Date: rR - a F DEPART ENT USE ONLY Application Accepted by Date ` U�Z_ Date 4-3>Pit or Grout Inspection by Date Final n�ibn by �' ��0✓ "Additional Comments: ❑ Stk 4664781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 is Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201' r. r- T FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. + EH13-24 1REV,1/-95) s � )L693 EH 1426