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" k 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;' (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 Ryles and Regulations of the San Joaquin Local Health District. Job Address r 1 r 3 V 1' pity Lot Size / C1.C1t. 'PM Owner's Name . (�12• YJ��,':.[1'2�� Address .7 C.�!`�}.�-(�t%ti`�. :lXZ-�-- �(=---. Phone - - Contracta� u ~� r:�1�C_,i Address p ), ISG �( C7License No. G Phone 3 c� �TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 171 3 DISTANCE,.TO.NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE -_ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack - ❑ Tracy Type of Casing Specifications r ❑ Public ❑ Other ❑,Delta Depth of Grout Seal Type of Grout Ll Irrigation --Approx. Depth ❑"Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump # H-R. State Work Done Well Destruction ❑ Well Diameter SealQ_Material atop 501 Depth Filler Material (Below 501 ' TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence _-L-__-Commercial_ Other Number of living units: -J— Number of edrooms s �� i I Character of soil to a depth of 3 feet: 't G ��1 Water table depth, . �~ •�: SEPTIC TANK l�Type/Mfg ��.� Capacity -0,6 No. Compartments ^� I 4 PKG. TREATMENT PLT. ❑ ---- --.- . - f Method of Disposal i r Y Distance to nearest: Well Sly Foundation ,..__ Property Line ------------- -- LEACHING LINE C7"-No. & Length-.of lines ^L t�F I ,�T`otal�length size FILTER BED ❑ Distance to nearest': Well .S!?^tet Foundation�16 Property Line S� SEEPAGE PITS R' Depth Size3 Number ' f SUMPS ElDistance to nearest: Well ?O Foundation!—�d . Property Lire DISPOSAL PONDS PONDS ❑ 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. l Home owner or licensed agents 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 applicant must call folk�r�quired inspections. Complete drawing on reverse side. ' 6 c Signed / /J Title: Date: l��tl`U" ys `� FOR DEPARTMENT USE ONLY Application Accepted_bV _Date —Area— -- or Grout Inspection by Dat Final Inspectionty zi- Additional Comments: ` G f/ _. — ❑'Stk 466=6781""'�'"!❑'Codi�`369=362T '-'"""❑-IVfartteca _823=7104-""�`❑Tracy 83546385 - Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. + EH13-24(REV.t/65) . EH 1426