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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 'I'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 Distric t. y Job Address / -3 2 �1_� City Lot Size r A Ic-5 A ftm Owner's Name AddressPhone ContractorS Addresses License No. '7 ._Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK .-- SEWER LINES ----_ DISPOSAL FLD, PROP. LINE ��t� FOUNDATION GRICULTURE WELL f OTHER WELL -- PITS/SUMPS Z,0 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO S �{ ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Ca��sinn/�� Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specification��Mi`f 1`19e_47 ( . M Public (-D Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation pprox. Depth l I Eastern Surface Seal Installed by_ ar - Repair Work Done ❑ Type of Pump _ _� H.P. r - State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material l8elow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION I I DESTRUCTION I 1 lNo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial— Other Number of living units: Number 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 Foundation Property Line (�4 LEACHING LINE ❑ No. & Length of lines Total length/size a FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number ' s SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin con-14 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 t'he w ofk for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." .,j,r R The applicant st requir tions. Complete drawing on rev se side. Signed,X Title: v �� Date: FOR DEPARTMENT USE d6y j} t Application AQcepted b _. ;%�,°� _— Date 10 D� Area 00 'r �'j• Pit or Grout InspeLtion by s Date k'If;L& Final Inspection Date Additional Comments: ❑ Stk 466-6781 C), Lo '369-3621 Ll Manteca 823-7104 ❑ Tracy 835 6•--s / Applicant- Return all copies to: Environmental Health Permit/Services 1601-E. Hdzelton 4e.`P.O. ox 2009, Stk., CA 95201 . FEE AMOUNT DUE AMOUNT REMITTED CK 4 CASH RECEIVEWEI DATE PERMIT-N0. INFO _ - ..E 13-24 IREV.i i n 5705 ` EH 11-28