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I 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 I (Complete in Triplicate) Application is hereby made to the SanJoaquin 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`fhe Rules and Regulations of the San Joaquin Local Health District. I Job Address l '! � - City FVC0.!O'Pll. Lot Size PM Owner's Name l)t?ry+d e�N GCfh`- Address l 00- [ � a�Ps Phone I ! / Contractor -P �! Address 7 S., IX-It —c License No.�Z—Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT D DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 17 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 industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing © Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F] Public M Other f_l Delta Depth of Grout Seal Type of Grout_ I I Irrigation —Approx. Depth l I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well DiameterSealing Material Itop 50'I or Depth / Filler Material (Below 501 d ` Q c r© TYPE OF SEPTIC WORK: NEW INSTALLATION i a REPAIR/ADDITION i I - DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: .Residence Commercial_ Other i . Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth r i I SEPTIC TANK El Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation-5-Zj " Property Line itk LEACHING LINE ❑ No. & Length of lines Total length/size i FILTER BED ❑ Distance/to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth IM Size Number SUMPS Cl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ IM 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 Di1trict. 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 " III The applicant t far all wired i1peComplete drawing on rey$r�se,side. p y Signed X II Title: Date: r L it F_00CEARTPANT USE ONLY Q' Application Accepted by Date / Q Area Pit or Grout inspection by I� ! Date Final Inspection by J� / /Date NZ d Additional Comments: .i1 c as 4 �9. arle� El Stk 466-6781 ❑ Lodi 369-3621 Manteca 823-7104 ❑ Tracy 83K-685 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I`. FEE INFO AMOUNT DUE! AMOUNT REMITTED GASH RECEIVED BY DATE PERMIT'NO. +.EH 13-24 1NEV.t R to EH 14-26