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Upl� y� =,,�` - •� '�-- 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 Rules and Regulations of the San Joaquin I Local Health District. it A,1 • ' Job Address c,2,362 � City �r Lot Size PM ti Owner's Name k1 Address ?41AQ , Phone S �35'�-Pei" �� ' t��/�` Phone Contractor Address (cense No. TYPE OF WELL/PUMP: , NEW WELL ❑ WELL REPLACEMENT>( DESTRUCTION ❑ + PUMP INSTALLATION ❑. SYSTEM REPAIR'❑_ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK /�II SEWER LINES DISPOSAL FLD. 'r*PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE .:I TYPE OF WELL �3_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 .� ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout_ ❑ Irrigation ±_-Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump, i H.P` State Work pone Well Destruction. El Well Diameter�s ' Sealing Material (top 501 Depth Filler Material (Below 501 Ah TYPE OF SEPTIC.WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is A. r. available within 200 feet.) Installation will serve: -Residence—, Commercial Other Number of living units: ` Numb e' of bedrooms( Character of soil to a depth of 3 feet: # Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ 1 Method of Disposal r r Distance to ta ...:....Wi�A Foundation Property Line f ' LEACHING LINE ❑ No. & Length of lines Total length/size ' FILTER BED ❑ Distance to nearest: Well Foundation F Property Line t SEEPAGE PITS El Depth Size Number SUMPS ❑ Distance to nearest: rWellFoundation Property Line 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, state laws, ander f rules and regulations of the San Joaquin.Local Health District. F 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 applicant i ust call for all requi inspectionsomplete drawing n verse side. " Signed Title: i ` =Date's _ � F R DEPARTMENT SE ONLY Application Accepted Date _�Ar'e`a _/5�7 M PR or Grout Inspec by Date l Final Inspection by •r - Date d trl Additional Comments: f. ❑ Stk 466-6781 ❑ Lai .369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 �� Applicant- Return ail copies to: Environmental Health Permit/Servioes.1601 E. Hazelton Ave., P.O. Boz 2009 mak., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED C RECEIVED BY DATE PERMIT NO. INFO + EH 13-24(AEV.i/es) `---�© t p EH 14-20 .. / ` C?,7 '-72_1p }. J1 .. r