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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT I 1601 E. HAZETON AVE., STOCKTON, CA led Telephone (209) 466-6781 J { 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 Lot Size X6/ PM Owner's Name 41 7yCts Address _1�a �� _ Phonu Contractorc Address�(� /°,2c :T'cv000 t'a License No. S7,��/Z7 Phone)-SOv722,%7u TYPE OF WELL/PUMP: NEW WELL ❑ , WELL REPLACEMENT ❑ `' a:,.DESTRUCTION ❑ PUMP iNSTALLAT-& ❑ SYSTEM REPAIR ❑ t OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE 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 ❑ Gravel Pack ❑ Tracy Type of Casing_________L Specifications f`l Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout _ I I Irrigation _-Approx.',Depth I I Eastern Surface Seal Installed by "A Repair Work Done ❑ Type of Pump, H.P. State Work Done Well Destruction ❑ Well Diameter+ Sealing Material Rop-•50') �C Depth 1er Materiai (Below 50') •" _ TYPE OF SEPTIC WORK: NEW INSTALLATION I.1 fiEPAlR/ DDITIONkl DESTRUCTION i I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial Other f 4 Number of living units: Number ofbedrooms2 v Character of soil to a depth of 3 feet: t Water table depth SEPTIC TANK ❑ Type/Mfg I �`F '� � Capacity No, Compartments PKG. TREATMENT PLT. ❑ I ' f Method of Disposal Distance t o.ri arest: Well xFoundation Property Line + w LEACHING LINE ❑ `No. & Length of lines t_ To`tal length/size FILTER BED ❑ Distance to nearest: Well R — —Foundation - —Property-Line.�— `b SEEPAGE PITS l I Depth g Size �i';Kl Number, LIMPS 0 Distance to nearest: Well 523 z 'Foundation_� Property Line � DISPOSAL PONDS ❑ I 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 Dtiltrict. Home owner or licensed agent's signature;certifies the following: g: 'I certify that in the performance of the work for which this permit is issued, E 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." Thea applicant must call f all re wired ins pP o� q inspections. Complete drawing on-reverse side. Signed X c/ Title: Z.) 4 d a Date: _e�' �nt, FOR DEPARTMENT USE ONLY Application Accepted b �,a)�(,)1[Ntr��•, `"u`� Date t Are Pit or Grout Inspection by ! Dat Final Hsps tion by to Z—` Z6' Additional Comments;44. ��_._ ❑ Stk 466-6781 ❑1-odi 369-3621: ❑ Me eca 823-7104 ❑ Tracy 5 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO UK 9 AMOUNT DUE r AMOUNT REMITTED CASH L RECEIVED BY DATE PERMlT'NO. ♦.EH 1324(REV.I/K 51 _� 7 .L [UV ..� jrL4�L� �.�, ��, V•� �� r EH 14-211