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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209.) 46676781 9 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 F Local Health District. �. R Q Job Address 1IIy " (�f3 1Y2'/ J•�lzity Lot Size 3 PM t Owner's Name 1IAh ;E-d� Address 779 0 e�41 r� Phone 7 Y� 3I Gantractor v ' G. Address. 7 Dai erase.Na.. `- -.P.hane TYPE OF WELL/PUMP:' NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ ' PUMP INSTALLATION `0. SYSTEM REPAIR ❑ OTHER ❑ 3 DISTANCE TO NEAREST: SEPTIC TANK SEWER;LINES u DISPOSAL FILE). ID PROP. LINE _L v I FOUNDATION AGRICUL'TURE,WELL / OTHER WELL PITS/SUMPS L:5-DQ INTENDED USE TYPE OF WELL PROBLEM AREA \CONST'RUCTION SPECIFICATIONS r ❑ Industrial Open Bottom ❑ Manteca. Dia.'of Well Excavation " " 1' Dia. of Well Casing 1 Domestic/Private E Gravel Pack ❑ Tracy :" ,4',,,Type of Casing Specifications D#4 0-PTic ❑'"Other ❑ Delta ' . 1 epth of Grout Seal ,Type of Grout El Irrigation '-LApprox. Depth ❑ Eastern -Sine Seal Installed by Repair Work,Done ❑ type of Pump H.P. ?, State Work Done Well Destruction Cl Wd Diamet Sealing Material {top 50') 1 Depth : Filler Mswrrial LB w 50'I fA_J I TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIADDITION ❑ DESTRUCTION ❑ {No septic system permitted if public sewer is f t. tiavailable within 200 feet.] Installation will serve: Residence_ Commercial Number of living units: `Numtie"r"of Character of soil to a depth of 3 feet: gib' Water table depth SEPTIC TANK ❑ Type/Mfg ti: Capacity No. Compartments PKG. TREATMENT PLT. ❑ `;• Method of Disposal Distance to nearest: Well Forty undation PropeLine LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: W� Foundation Property Line ' SEEPAGE PITS ❑ Depth Size Number y SUMPS ❑ Distance to nearest: Well nation Property Line 4shall DISPOSAL PONDS ❑I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, srules 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 iss employ any person in such mariner 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." q The applicant must r all required ins ctions plate drawing on 7;4,&Aai� side. Signed # fy } � yl1 Title: Date: Q Ar FOR DEPA TMENT USE ONLY ' ^ Application Accepted by `� Date v 'Z Area f SI t Pit o�J Inspection by ate ~incl Inspection by, Date t Ad itional Comments: VStk 466-6781 LI Lod! 369-3621 El Manteca 823-7104- ❑ Tracy 835-8385 i p licant- Return all copies to: Environmental Health Permit/Services 1801 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE i INFO AMOUNT DUE AMOUNT REMITTED CK 0 CASH RECEIVED BY DATE PERMIT N0. + EH 13-24(REV.i/a 5) EH 14.26 b, �O