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I y� APPLICATION FOR PERMITS SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA No Telephone 12091 466-6781 C� Vol-liR0k [;irorz 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 I made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 18&2 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. _ Job Address _ �� QLPfi}�(',_�=F. .._.. City Lot Size SV x PM Owner's Name Address .S'2-40 Phone 3 3 Contractor _/� W�r�� Address fed s N' .01"W ,t!A-icense No. '� Y7� Phone 97 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ O ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESDISPOSAL PROP. LINE FOUNDATION AGRICULTURE WELL OT ELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCJJj&W SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. ell Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy ype of Casing I Specifications \ t ❑ Public ❑ Other ❑ Del Depth of Grout Seal Type of Grout oma, Ir ❑ Irrigation --Approx. Depth_. astern Surface Seal Installed.by �1 Repair Work Done ❑ Type of Pum t �! H.P.; State Work Done Well Destruction ❑ Well eter Sealing Material (top 50') epth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION y❑ DESTRUCTIONX fNo septic system permitted if public sewer is _ t I available within 200 feet.) Installation will serve: Residence ; Commercial_ Other Number of living units: Number of bedrooms __...� Character of soil tc a depth of 3 feet: f Water table-depth- SEPTIC TANK ❑ Type/Mfgj - - — Capacity No.'Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well f Foundation Property Line i LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: .Well Foundation Property Line I SEEPAGE PITS ❑ Depth Size, i3- 1,Number jSUMPS ❑ Distance to nearest: Well Foundatior � o Property Line DISPOSAL PONDS ❑ o 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. I I Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this petmit is issued, I shall not employ any person in such manner as to becorne-subject to workman's compensation laws of.California."Contractors hiring or sub-contracting signature certifies the following: '9 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 applicant must call fo all required inspections. Comp to drawing on reverse_side. Signed Title-7- Date: _ �� FOR DEPARTMENT,USE ONLY Application Accepted by e` 1 _rpt ztiF _ __ Date5� b-?37 ]7 Area l Pit or Grout Inspection by Date Final Inspection by !' Date �� z I Additional Comments: 4J74JjdZX ❑ Stk 466-6781 0 Lcfdi 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 i INFO AMOUNT DUE AMOUNT REMITTED CK RrECE,,IV_ED BY DATE PERMIt'NO.=200f+EH 13-24(REV.1/B 5) r��00 ��" v a l f1�! , _J�W.(fit �-7 EH 14.26 _ EE4..•JJJ d f