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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 3 0. r.+�, l C_i . L c F.P 194 SAS,! JOAQUIN LOCAL w7p i Ty nl(ZTP!rT (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 !+%i'( !! _ _ City Lot Size 71t PM t 4�_ T Owner's Name 1�93__Address LtIUiK) 7►1�:4�jlO phone Contractor's Name T License No. V11�110A/3 Phone 6v5-` l/ G?S TYPE OF WELL/PUMP: NEW WELL )9L WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST:..SEPTIC_TANK.Z,20 " SEWER LINES ---,,,,,,—,-DISPOSAL FILD. Q0 ' PROP..LINE,� _ t .,FOUNDATION �� AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE ❑ Industrial Domestic/ Private ❑ Public ❑ Irrigation Repair Work Done ❑ Well Destruction Cl TYPE OF WELL ❑ Open Bottom "-Gravel Pack L7 Other ---Approx. Depth Type of Pump Well Diameter; Depth PROBLEM AREA CONSTRUCTION SPECIFICATIONS Manteca Dia. of Well Excavation ❑ Tracy Type of Casing ❑ Delta Depth of Grout Seal J ❑ Eastern Surface Seal Installed by H. P. State Work Done _ Sealing Material /top 50') Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DEST Installation will serve: Residence—'. Commercial Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg PKG. TREATMENT PLT. ❑ Other Capacity Distance to- nearest: Well Foundation LEACHING LINE ❑ No. & Length of lines Total FILTER BED ❑ Distance to nearest: Well Foundation I� Dia. of Well Casing Specifications o ype-of Grout (No septic system permitted if public sewer is available within 200 feet.) Water table depth _ No. Compartments Method of Disposal Property Line Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ' ❑ -- Distance to nearest: _-- -Well-' —�-Foundation Prcio&ty-Lirie" 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. 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, I shall employ persons subject to workman's compensa- tion laws of California." The appli nt m st call for all required in ctions. Complete drawing on reverse side. Signed X A itle: Date: `7 R DEPARTMEN USE ONLY �-- Application Accepted by Date �(� Area Pit a rout spection by t� - ._= =nate /b _9 idirill Inspection by A.L.,. Date f0^3 ^� Additional Comments: -5-f ❑ Stk 466-6781 ❑ Lod! 369-3621 A!�-fManteca 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 CA H REC15IVED BY DATE PERMIT NO. + EH 1324 {REV, 14/631 EH 14.28 - 1 c?b - ��. �� f/� �H•-tib,