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f� APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 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 Rulas and Regulations of the San Joaquin t Local Health District. Job Address ..5 2 C ' City Lot Sized PM Owner's Name. Address aS`l 7� zPhone ContractortU�/ Address /"`Q J c�/Cf �� License NoQ�7�t Phone 36�3f13 TYPE OF WELL/PUMP NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ T DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. rPROP. LINE } FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS `vt Ll Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing v f ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 11 Public F1 Other Cl Delta Depth of Grout Seal Type of Grout _ 1 1 Irrigation T --Approx. Depth I I Eastern Surface Seal Installed by "' Repair Work Done ❑ Type of Pump H,P. State Work Done_ 1 1 ,Well Destruction ❑ Well Diameter ►..---Sealing-MateriaL.{top.50) 1 : Depth Filler Material {Below 501 r , TYPE OF SEPTIC WORK: NEW INSTALLATION CI AEPAIR/ADDITION DESTRUCTION l I Wo septic system permitted if public sewer is �. available within 200.feet.) Installation will serve: Residence✓Commercial Other Number of living units:, Number of b rooms ;. r , Character of soil to a depth of 3 feet: Water table depth SEPTIC iTANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal f `jam= Distance to nearest: Well Foundation Property.Line e LEACHING LINE V+�No. & Length of li s O 1 Total length/size 0 .j FILTER BED ❑ Distance to nearest: Well / .c�J r Foundation I Property Kine SEEPAGE PITS } l4 Depth Size �7�4e [Number Z�`� SUMPS ) Cil` Distance to nearest: Well jS CJ Foundation f f Property Line 2 DISPOSAL PONDS A s 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. �,� t � l\ I 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 compensationaaws 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 applicant must call for all required i sn ' f pections. Complete drawing on reverse side.• � Signed X F-, - _ -,Title:iow#+4� Date: J FOR DEPARTMENT USE ONLY Ap lication Accapted by Date✓ R Area i j t it r Grout Inspection by Date rg12 Final lns'pection by !! Date��`Y Additional Comments,. I _w.W. ❑ Silk 466=6781""'"rCl'Lodi•""'3fi9=3621--'❑Manteca 623-7104 O Tracy j 835-6385 � Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. HazeltonnAAve., P.O... Box 2009, Stk., CA 95201 FEEINFO AMO��U}}NT/D�UE AMOUNT REMITTED . C SH RECEIVED BY DATE PERMIT'NO. +,EH1C220eIgEV.kiH51 0, do ! e, X� _