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I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ' (Complete in Triplicate) Application is he+eby 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 Sari 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., l ` - city Lot Size PM Jab Address �y��/j�� Zr�� Owner's Name /`✓� r/ � Address Phone Contractor g0fMAI Address LZjaicense No"& Phone k TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ HER ❑ / i DISTANCE TO NEAREST: SEPTIC TANK r0--�f SEWER LINES �` DISPOSAL FIL RROP. LINE FOUNDATION AGRICULTURE WELL �� OTHER WE L PITS/SUMPS "4- INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION j J� 171 Industrial El Open Bottom ❑ Manteca Dia. of Well Excavation Dia..of Well Casing Domestic/Private ,VGravel Pack ❑ Tracy Type of Casing Specifications GL I f l Public 1-1 0)her ❑ Delta f Depth of Grout Seal Type of Grout�1 . I I Irrigation 2�-Approx. Depth t.IILastern JSu e meal Installed by �w -.�. r✓Q /�..r Repair Work Done ❑ Type of Pump• H.P. ' r State Work Done Well Destruction .. ❑ Well Diameter Sealing Material Itop 50'1 i Depth Filler Material (Below 50'I i TYPE OF SEPTIC WORK: NEW INSTALLATION I } REPAIR/ADDITION 1 I DESTRUCTION I I lNo-septic system permitted if public sewer is available within 200 feet.) �4 Installation will serve: Residence Commercial_ Other 1 _-� Number of living units: Number of bedrooms t. Character of soil to a depth of 3 feet: IE., - Water table depth SEPTIC TANK ❑ Type/Mfg Capacity 1 <-` No. Compartments PKG. TREATMENT PLT. ❑ 'Pr, Method of Disposal i Distance to nearest: Well,. 1� Fo0ndation Property Line rN LEACHING LINE ❑ No. & Length of lines �gLNU ITotal length/sizer FILTER BED EJDistance to nearest: t Well Foundation �' z Property Line s SEEPAGE PITS I I Depth l Size Num`5ar s t SUMPS 0 "Distance to nearest: Well s,Foundation .PropertyQir}e DISPOSAL PONOS. ❑ I hereby certify that I have prepared this application anld that-the work yXill be don«-accordancdinrifll Joatjuin county ordinances,'state laws, and. 4 rules and regulations of the San Joaquin Local Health bi'strict>0- Homeowner -Homeowner or licensed agent's signature certifies the following: "I certify that in xhe.performance of the work or which this permit is issued, I shall not employ any person in such manner as to become subject workman's compensat=laws of California."�Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the rk for which this permit is issued, I shall 4mploy persons ubject to workman's compensa- tion laws of California." The applicant=CIall equir I s. Complete drawing on rev side. �7 Signed X Title: ate: 1 I FOR DEPARTMENT USE ONLY Application'Accepted by Date 2 t Area i Pit or Grout Inspection by Date,`/f9I Final Inspection by Date ®�" IYWIt Additional Comments: +�C� �e- D / f 117/bQ fk i 6 IW ❑ Stk 466-6781 ElLodi 369-3621 ElManteca 823-71134 ❑ Trac 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bo 2009, Stk., CA 95201 7Z - FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE ; PERMIT'NO. INFO CASH I +.EH13-24 1REV.t/x 51 1/0 ' 2 EH 14-28 _