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a I it APPLICATION FOR PERMIT I! SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone {209} 466-6781 ' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �i (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. �fSA-114-a:5 L � Job Address L �>.�[32,z) <�,17- City Loi Size PM i Owner's Name W- sniff Address, Y3 Phone Contractor's Name '.2'T-rUIGCa!� License No. 7�i�5`�'z Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION! ❑ PUMP INSTALLATION ❑ L 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private EI Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ! LJDelta ...... Depth of Grout Seal Type of Grout C1Irrigation --Approx.,Depth ❑ Eastern Surface Seal Installed by. e Repair Work Done Type of Pump H.P. i State Work Done 9(, N Well Destruction LJWell-Diameter Sealing Material (top 501 _ Depth !N. Filler Material IBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION PC REPAIR/ADDITION'❑ DESTRUCTION ❑ INo septic system permitted if public sewer is vailable-within-200-feet.)-=—,—:5 Installation will serve: Residence 1_ Commercial_ Other Number of living units: Number of bedrooms _ r' Character of soil toia`depth of 3 feet'p I ege Water table depth SEPTIC TANK ' 0. Type/Mfg Capacity_ .e� No. Compartments PKG. TREATMENT PLT:`❑: �G I�Lt.Nrgs/ "sem.. Method of Disposal " /Distance to nearest: Well Foundation �l!� Property Line LEACHING LINE `i$ No. & Length of-iines" Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line ^ SEEPAGE PITS ❑ Depth !M Size f ;-� Number SUMPS ❑ Distance to nearest WeII Foundation Property Line, DISPOSAL PONDS ❑. 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 th0ollowing:-"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 ttieperfor4y�ance-of-the-work far-which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." , 11: The applicant must call for all required inspections. Complete drawing on reverse side. Signed b 4 Title:— R Date: � . FOR DEPARTMENT USE ONLY Application Accepted by Date Area 7 /I?I:/, �i•�� Pit or Grout Inspection by � Date � I II p Inspection by Date Additional Comments: �� T ❑ Stk 466-6781 1-] Lodi 369-3621 EIManteca x/623-7104 ^^ ❑ Tracy, 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave.,".P.O. Box 2009, Stk., CA 95201 INFOMOUNT DUE �� AMOUNT REMITTED CASH RECEIVED BY DATE PERM(T`N0. q6ri" I (1 " +EH 1324(REV.10!831 EH 1428