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APPLICATION FOR PERMIT ,Q 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) 7 �/L1 rZ,-(`7—c3�- 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 e b 1 3 f City C 0`{Lot Size 10 ! PM Owner's Name ��V4dClr CUer _ Addresstti (1f1lAPhone U��r�"ftQJ Contractor MA411A I PUS Address eeed M License No. 30-95-1 Phone_ 'b3q TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK -- SEWER LINES DISPOSAL FLD� PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I S/ tl ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing I Domestic/Private Gravel Pack ❑ Tracy Type of Casing , Specifications �p a [`l Public Ll Other n Delta Depth of Grout Seal Type of Grout +/c I I Irrigation � Approx. Depth J I Eastern Surface Seal Installed by_77 - Repair Work Done ❑ Type of Pump _ H.P. 1�+�2 State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 501 " Depth ft Filler Material (Below 50') -- TYPE OF SEPTIC WORK: 'NEW INSTALLATION.['] REPAIR/ADDITION I I DESTRUCTION I ] iNo septic system permitted if public sewer is i available within 200 feet_.I r Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: ¢_ Water table depth s, Q I. SEPTIC TANK `. ❑_7ypellft Capacity No. Compartments., PKG. TREATMENT PLT. ❑ ' Method of DisposF al t t I� Distance to nearest: Well Foundation Property Line I : LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITSY Cl Depth Size _ Number SUMPS Gl Distance to nearest: -..Well, Foundation Property tine ,r) N 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, and f 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 p6rsons.subject to workman's compensa- tion laws of California." The applica st cal!for all required inspections. Compl drawing on reverse side. / Signed X 1 Title:' ' Y Date: 2 L I�-q .� -•. FOR DEPARTMENT USE ONLY �] r Application Accepted by Date 4L— �*4 a D Pit or rout Inspection b DatFinal Inspection by� Dati�'�� Additional Comments: a ' — :; ❑ Stk 466-6781 odi 369-3621 �0 Manteca 823-71 ❑ Tracy"835 5, Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 + FEE AMOUNT DUE AMOUNT REMITTEDK H RECEIVED BY D TE PERMIT'NO. �I I INFO /!TT o[,J II ♦ EH 13.24(REV.t i n U PA/ EH -28