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I 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 Rules and Regulations of the San Joaquin Local Health District. Job Address City Lot Size A� PM Owner's Name 'SAV /"A7'7„L/r _ Address Phone J Contractor�L-rg'1� F, - lt/�(37>.�Address 7 /�•� A�6LA�2-7' �'�• w- License No. .r 76 Phone r-3 YZ TYPE OF WELL/PUMP: NEW WELL 0 FWELL REPLACEMENT ❑ DESTRUCTION ❑ i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 4 OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE i TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial f ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Diai 11 . of Well Casing /�+ (�,_• ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing 'Specifications K# 011, ['1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout f _ { i I Irrigation ____..Approx. Depth. I I Eastern Surface Seal,lnstalled by Repair Work Done 01 Type of Pump H.P. - State Work Done_ f° Well Destruction ❑ Well Diameter Sealing Material (top 50') f f Depth Filler Material (Below 50'1 r f f TYPE OF SEPTIC WORK; NEW INSTALLATION 1 i REPAIR/ADDITION' DESTRUCTION I i INo septic system permitted if public sewer is 'available within 200 feet.) i Installation will serve: Residence .iCommercial_ Other . Number of living units: _._.L_— Number of bedrooms r i� Character of soil to a depth of 3 feet. - � Water table depth t SEPTIC TANK ❑ Type/Mfg — ��tr Capacity No. Compartments PKG. TREATMENT PLT. ❑ i Method of Disposal f Distance to nearest: Well FouunndatOn Property Line LEACHING LINE �I No. & Length of lines�� -.'fly Total length/sized ` '= FILTER BED ❑ Distanc'e to'nearest: I Well f�Cl ` Foundation 3e, Property Lirie' SW` SEEPAGE PITS ("Depth l 359 —Size _ zz — Number SUMPS f ❑ Distance to nearest: Well Foundation 30 Property Line DISPOSAL PONDS ❑ I hereby certify that I fiave 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. 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- tionjaws of California." The applicant must call for all required inspections. Complete drawing on reverse side. I Signed X Title: C.../� 1t,4_ Date: ®" FOR DEPARTMENT USE ONLY 1 a Application Accepted by Date10 "y <K SArea _ Pit or Grout Inspection by Date f t/- 0 4 Final Inspection by Date/22 Additional Comments- / f _ ❑ Stk 466-6781 ❑ Lod 369 j3621 ❑ Manteca •823-7104 ❑ Tracy 835-6385 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 CASK RECEIVED BY DATE PERMIT'NO. +. 00 EH t3-24(kEv.,/H 51 f� 9 V I� /1")_ '54 rte'>ir''4 EH 14-26 r V (`'