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APPLICATION FOR PERMIT �9 SAN JOAQUIN LOCAL HEALTH DISTRICT v' 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 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: Cityf��-"�16n! Lot Size /� �Q, PM Job Address /I�1 Owner's Name �-1� Address L� Phone 1 o Contractor 0 cow F_fc- Address License No. _ Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ 'DESTRUCTIONY 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 C1 Industrial ❑ Open Bottom 171 Manteca Dia. of Well Excavation Dia. of Well Casing D Domestic/Private El Gravel Pack ❑ Tracy Type of Casing Specifications 1"1 Public XOther Ll Delta Depth of Grout Seal Type of Grout --- I I Irrigation �Approx. Depth I i Eastern -Surface Seal Installed by Repair Work Done ❑ Type of Pump / +ir1�/4 �/A�IkState Work DoneWeli Destruction Wel! Diameter Sealing Material .�mF�+l"T Ce�Pnc17' 3� �i2ow Sv�eF+3c>` Depth •12c�i Filler Material (Below 501 SAr'(o TYPE OF SEPTIC WORK: NEW INSTALLATION is RFPAIRIADDITION I I DESTRUCTION I 1 o septic system permitted it public sewer is available within 200 feet./ Installation will serve: Residence Commercial_ Of or y. Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ , Type/Mfg Cap No. Compartments PKG. TREATMENT PLT. ❑! Method of Disposal l Distance to nearest: Well Fou n a on Property.Line i LEACHING LINE ❑ No. & Length of lines Z Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size umber SUMPS L-1: 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—b<Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health Di§trict. 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." The applican st call or all r it in ctions. Complete drawing on reverse side. - Signed X _ Title: Date: �S FOR DEPARTMENT USE ONLY Application Acceptedby t __ Date S Area_/u 3 Pit or Grout Inspection by Date Final Inspection y Date Jit Additional Comments: Ax © Stk 466-6781 Ladi 369-3621 ❑ Manteca 823-7 ❑ Tracy 835-0685 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE P� INFO AMOUNT DUE AMOUNT REMITTED K H RECEIVED BY DATE PERMIT NO. Q N/ a.EH 13-24 IREV.1 i n 51 EH t4-26