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I APPLICATION FOR PERMIT SAN JOAO.UIN,LOCAL HEALTH DISTRICT 1601 E. HAZELTON.AVE., STOCKTON, CA Telephone (209) 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 1 Local Health District. - a'. Job Address �9�� I�DGZ--. E City Lot Size ��C 1 s'O PM _ Owner's Name A?_ Address 5ALOV47 Phone 3—A3 5EO Contractor r 1? j5:iLtJOD cAddre-ss a<iEYAl. L I,-.4yo4AI License No.'yyS.Z7f� Phone TYPE OF WELL/PUMP: NEW WELL,❑ `. WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION❑ SYSTEM REPAIR'❑ +OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES - DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL A OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ GraveliPack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal i Type of Grout ❑ Irrigation _- 4pprox. Depth ❑ Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 f Depth 4 Filler Material (Below 501 It TYPE OF SEPTIC WORK: NEW INSTALLATION.❑.- REPAIR/ADDITION ❑ DESTRUCTIONA (Na septic system permitted if public sewer is { available within 200 feet.) Installation will serve: Residence Commercial— Other a Number of living units: Number of bedrooms F ' Character of soil to a depth of 3 feet: ` .*�'. Water table depth SEPTIC TANK ❑ Type/Mfg Capacity `, No. Compartments PKG. TREATMENT PLT. ❑ 1 Method of Disposal Distance to nearest Well Foundation Property Line LEACHING LINE ❑ No. &Length of lines Total length/size FILTER BED 11Distance to nearest: Well Foundation Property Line r SEEPAGE PITS ❑ Depth' Size T >_ Number s SUMPS ❑ 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. r t Home owner or licensed agent's signature certifies the following: "1 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 workmdn'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." F' The applicant must call for all required inspections. o pletesdrawing on reverse side. Signed a Title: _ mm .�. Date: `X�FOR DEPARTMENT USE ONLY _ to Area Application Accepted bya - Inspection b Date Final Ins on Date Pit or Grout Ins c y Additional Comments: ❑ Stk 4664781 Codi 3 6-3621 ❑ Manteca 823-7104 ❑ Tracy Applicant- Return all copies to: Environmental H90t7h JPermit/Services 1601 E. Hazelton Ave., P.O. Bax , Stk., CA 01 k FEECK RECEIVED'BY DATE PERMIT'NO. INFO AMOUNT DUE AMOUNT REMITTED _ CASH c. 7 y + EH 13-24 EH 14.28 1REV.t/957 ;7.