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i APPLICATION FOR PERMIT F SAN JOAQUIN LOCAL HEALTH DISTRICT f 1601 E. HAZELTON AVE., STOCKTON, CA Elf- Telephone (209) 466-6781 PERMIT EXPIRES 7 YEAR FROM DgTE 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 made H compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for wail/pump and the Rules and Regulations of Local Health District. ribed. This Sa ication is "an Jr7 y DaQUIn Job Address - , I - City Lot Size l' Owner's Name V L © ' y �i �O 4 e' ("A, Address PM l � Phone Contractor 1 r IV fs- Address TYPE OF WELL/PUMp: NEW WELL ❑ License No Phone Q PUMP INSTALLATION ❑ WELL REPLACEMENT ❑ DESTRUCTION t�: DISTANCE TO NEAREST:. SEPTIC TANK SYSTEM REPAIR ❑ OTHER C]SEWER,LINES L FOUNDATIONF —� DISPOSAL FLD. PROP. LINE AGRICULTURE'WELL OTHER WELL INTENDED USE TYPE OFWELL PROBLEM AREA PITS/SUMPS ❑ Industrial AR CONSTRUCTION SPECIFICATIONS ❑ Open Bottom ❑ Manteca Dia. of Well Excavation y ' ❑ Domestic/Private ❑ Gravel Pack Dia. of Well Casing ❑ Public ❑ Tracy Type of Casing ❑ Other ` El Depth of Grout Seal s Specifications ❑ Irrigation ---Approx. Depth ❑ EasterType of Grout i I' Repair Work Done ❑ T n Surface Seal Installed by Type of Pump H.P. Well Destruction ❑ Well Diameter ~~ State'Work Done Sealing Material (top 50') Depth TYPE OF Filler Material (Below 501) J \� SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑_ DESTRUCTION L " (No septic system permitted if public sewer is � Installation will serve: Residence— Commercial_ Other _ available within feet.) � S'-5-#–hv. Number of living units: Number of bedroomsCharacter of of soil to a depth of 3 feet: ' ,r � `•..'+�'J SEPTIC TANK ❑ Type/Mfg J Water table depth PKG. TREATMENT PLT. ❑ Capacity _ -_No. Compartments f Distance to nearest; i Method of Disposal Well '1�2. Foundation Property Line LEACHING LINE ❑ No. & Length of lines 6 FILTER BED El Distance to nearest: Well Total length/size Foundation Property Line SEEPAGE PITS ❑ Depth Size SUMPS E) Distance to nearest: Well NumlierF . DISPOSAL PONDS ❑ Foundation Property Line I 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 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 became subject to workman's compensation laws of California."Contractor's hiring or sub contracting signature certifies the followin r g:"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 must tali f all r quire inspections. Complete drawing on reverse ide. Signed Title: ' r �. . . -. ...-- -._ .- -_ • Date w � -� / FOR DEPARTMENT USE ONLY Application Accepted b Final 1_ �� Date Area. Pit or Grout Inspection by Date ` nal Inspection by Data Additional Comments; f ❑ Stk 466-6781 ❑ L&P 369-3621 ❑ Manteca 823-7104 f❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED INFO CASH RECEIVED BY DATE pPERMIT`NO. + E"13-24 1/e51 EHH F4f4-24 W