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APPLICATION FOR PERMIT SAN JOAQUIN-LOCAL HEALTH DISTRICT 1601 E. HAZ€LTONNAVYE., STOCKTON, CA Telephone 1209) 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 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 Z �'� I -7 �• a0d _ -City Ma4cLa..& Size PM QQ / !1= J� i cC3 Owner's Name ��.II J tr ew I.S Address / ��r Phone GST Contractor l Address 3 23 0 Z License No. hone 6 i6 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM,REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES # ''f DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL--' OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRI3CTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well'Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 171 Public Cl Other ❑ Delta Depth;of Grout Seal Type of Grout I I Irrigation _.-Approx. Depth 1 I Eastern Surface Seal installed byJ. _ Repair Work Done ❑ Type of Pump H,P. j f. State Work Don at Well Destruction 6K Well Diameter Sealing Material (top 50') C� Y1j t+L Depth 3rn Filler Material (Below 50'1 t� TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION l 1 DESTRUCTION l 1 (No septic system permitted if public sewer is available within 200 feet.) L Installation will serve: Residence q I—_ Comrilercial._ ,Other ( n Number-of-living units: .—Number of.bedrooms- Character of soil to a depth of 3 feet: ' Water):table depth SEPTIC TANK ❑ Type/Mfg Capacity .m No."Compartments PKG, TREATMENT PLT. ❑ /I F G Method of Disposal t Distance to nearest: Well Foundation ,Property Line _N , LEACHING LINE ❑ No. & Length of lines n- Tote1,14rigih/size { FILTER BED ❑ Distance to nearest: Well Foundation -jf_ Property Line ; SEEPAGE PITS 1 1 Depth Size ( Number SUMPS 0 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS © f 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. ; LLL , Home owner o -sed age '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 Orson in such ner as to b ome subject workman's compe6sation laws of California."Contractor's hiring or sub-contracting signature certifi(X— T following: 'I ce 'y that in t r an of t e work for which this t s-issued, I shall employ persons subject to workman's compensa- tion la Calif rnia." Theant m t f all to ed wing on re se Signe Title: Date: t F USE ONLY Application Accepted by Z, L Date Pit or Grout Inspection by Date Final Inspection b Additional Comments: ❑ Stk 466-6781 C1 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 FEE INFO AMOUNT DUE AMOUNT REMITTED ASH CK 49 RECEIVED Y DATE PERMIVNO. *.EH 13-24(REV.1/K5) — uWO4i_ ]� -�A� EH 14-26 (�