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APPLICATION FOR PERMIT t� SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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 d ` City IE3 C�/i7 Lot Size �� PM L..f, ISI(u A 141 C Address Phone Owner's Name _., Contractor Address . ar T� PU 16 �- P.Oq License No. Phone q ' i TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION FA_ SYSTEM REPAIR ❑ OTHER ❑ l DISTANCE TO NEAREST: SEPTIC TANK 10011 SEWER LINES DD 4 DISPOSAL FLD. PROP. LINE % b0I FOUNDATION -- AGRICULTURE WELL OTHER WEI-L �_ PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial El Open Bottom E1 Manteca Dia. of Well Excavation Dia. of Well Casing 10 / [,Domestic/Private F Gravel Pack 0 Tracy Type of Casing S � Specifications f M Public [1 Other Cl Delta Depth of Grout Seal �. A2A Type of Grout I I Irrigation /�nZ/Approx. Depth I I Eastern Surface Seal installed by Repair Work Done 0 Type of Pump H.P. _I State Work Done Well Destruction ❑ Well Diameter Sealing Material [top 50'1 �3 i Depth Filler Material (Below 501 I TYPE OF SEPTIC WORK: NEW INSTALLATION l;l REPAIRIADDITION I l DESTRUCTION I l Mo septic system permitted if public sewer is V� available within 200 feet.) ,) l Commercial Other Installation will serve: Residence 11 Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth \ - I SEPTIC TANK ❑ Type/Mfg I Capacity No. Compartments PKG. TREATMENT PLT. ❑ '� Method of Disposal I Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of linos ( Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth —Size.-- � _ _ Number SUMPS ❑ Distance to nearest:rest: -T Well--+ ---- Foundation �': Property Line q' DISPOSAL PONDS ❑' t Qy§ r � t 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 Diltrict. j- (_ .. Home owner or licensed agent's signature-certifies-the.followiing: "I certify that-in the performance of the work for which this permit is issued, I shalt not employ any person in such manner-as•6..become subject to-Workman's compensation laws of California."Contractors hiring or sub-contracting signature i certifies the following: "I certify that in the performance of the woik for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant Rutsttalf rZinspe inspections. lete dra Ing on reverse side. _` b Pt 7 Signed Title: DateDEPARTMENT SEONLYApplication Accepted by4 'Date rea Pit o rout I spection bDate Final Inspection by Date Additional Comments: a w6 i ,gird d �� `rl ,"F-A ❑ Stk 466-6781 Codi 369-362 C1 Manteca 823,6,1& CJ Tracy 5- 4,� Applicant - Return all copies to: Environmental health Permit/Services 1601 E. Hizalton Ave., P.D. Box 2009, 5tk., CA 95201 ) r r. I FEE AMOUNT DUE AMOUNT REMITTED CIC RECEIVED BY DATE PERMIT NO. INFO CASH +.EH 13-241REV.iin51 ' EH 14-26