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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON 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 Local Health District. Job Address 7l" / -n-` d kE6 City Lot Size PM Owner's Name �r�Y14'1C[I'? a dr17AAddress Phone 165— GO Contractor �SCW Address X2 MO %-56C16k O/ License No. 1,C-3 2— L 3 Phone /�5 TYPE OF WELL/PUMP: NEW WELL — / WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION LU/ SYSTEM REPAIR ❑ OTHER ❑ \ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS — INTENDED USE TYPE OF WELL PR03LEM AREA CONSTRUCTION SPECIFICATIONS Ll Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 7 a Dia. of Well Casing 8 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f` Public ❑ Other ❑ Delta Depth of Grout Seal 4/0 Type of Grout t 1 Irrigation —Approx. Depth l I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material atop 50') Depth Filler Material (Below 50') TYP OF SEPTIC WORK: NEW INSTALLATION (l REPAIR/ADDITION l I DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: dente Commercial T Other Number of living units: r 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 Fo tion Property Line LEACHING LINE ❑ No. & Length of lines To gth/size FILTER BED ❑ Distance to nearest: Well Foundation Prop Line SEEPAGE PITS I 1 Depth Size Number SUMPS L� 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. 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 shalt 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 California." The applicant must call for all required inspectio Complete drawing on reverse side. Signed X— � �Q�� Title: � � Date: �j FOR DEPARTMENT USE ONLY Application Accepted by 1/ 'A I - Date Area Pit or Grout Inspection by Date Final Ins ection by Date 7-1 ZU Additional Comments: ❑ Stk 466 6781 KLi .3 1 ❑ Manteca 823-71 ❑ T acy 835-6385 Applicant Return all co: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO FEE AMOUNnT DUE AMOUNT REMITTED CK 9 CASH HEGEIVED BY DATE P�EyR�MIT NO. + EH t3-241REV.I/KtO FJ/ yftfl EH 1426 l�'� /