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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA I Telephone (209) 466-6781 I 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 r Local Health District. F to [� f ` City Lot Size it PM Job Address �� J P Owner's Name �'r �4 Address Phone E Contractor L L Address C � nse No.`� Q� Phon e i TYPE OF WELL/PUMP: �i NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ 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 PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑�O en Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well 1-1 Industrial p i NCasing ❑ Domestic/Private ❑Gravel Pack - ❑ Tracy Type of Casing Specifications f ❑-Public 171 ❑ Delta Depth of Grout Seal Type of Grout_-_ I I Irrigation _11 -Approx. Depth I 1 Eastern Surface Seal Installed by (K Repair Work Done ❑ - Type of Pump H.P. State Work Done 4 _ Ip �' it Well Destruction L! Well Diameter Sealing Material (top 501 r L Deoil pth - Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION-i 1 REPAIR IADDITION1 I DESTRUCTION septic system permitted if public sewer is I ; available within 200 feet.) �` Installation will serve: Rio idence Commercial_ Other --- -- _-�- Number of living units: .11 Number of bedrooms I t Character of soil to a depth of 3 feet: i Water table depth SEPTIC TANK ❑I Type/Mfg —Capacity— No. Compartments PKG. TREATMENT PLT. ❑ f Method of Disposal IM Distance to nearest: Well Foundation Property Line I LEACHING LINE 0 No. & Length of tines .� •`"� Total length/size. M FILTER BED ❑ Distance to nearest: Well 4Foundation i Property tine E SEEPAGE PITS 1 1 Depth Size Number I ' SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ ' E A I hereby certify that I have prrapared this application and that the work w_till b_e done_in,accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. s ;� Horn wner 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 an on in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the n in "I ce y that in the performance of the work_for which this,permit-is,issued, I shall employ persons subject to workman's cdmpensa- 1 tion laws of 'The applicaS^111 or f r ins cion p1 to drawin o reverse de.Sign � Title. Date: FO ENT USE ONLY Application Accepted,by _`f�to[1. lfV� r-_ � Date �. Area M tl^T r Pit or Grout Inspection by to -�� Final Inspection by �s C�) !i Date. l ,.. Additional Comments: � _ _ G _ec. -. . a O Stk'466-6781 "❑ Dodi 369-362t p'C7 Mant_eca 823 7104^ ❑ Tracy 5-6NIS Applicant - Return all copies to: EnviroKmental Hee`lth'Permit/Services 1601.E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT 'NO. INFO r + EH 1 -241HEV.i C55Fc9U C�[3 JAk ,2, fH 144-28