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i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA i Telephone (209) 466-6781 PERMIT EXPIRES i YEAR 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 Ido.549 for sewage or No..1862 for well/pump and the Rules and Regulations of the San Joaquin _Local Health District. ,- Job Address b[(o ! ' a(((Jll City Lot Size PM Owner's Name Address 30l J • 0~ h Phone Contractor �e —Address—Po yk 2 License No. Phone_"110 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ l OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK_ SEWER LINIES' DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done , Well Destruction ❑ Well'Diameter - Sealing Material(top 50'I�'� t Depth Filler Material (Below 501 I TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION EJ-.(No septic system permitted if public sewer is © + r 1+ available within 200 feet.) i Installation will serve: Residence Commercial " Other Number of living units: Number of bedrooms Character of soil to a depth of 3feet: -—5—ACA( to an— - _ Water table depth SEPTIC TANK El Type/Mfg J0`� L. G�SYfG � Capacity 00 No. Compartments PKG. TREATMENT PLT. ❑ ,', �`k.. ,_c ti -1-�;; / Method of Disposal Distance to nimrest: Wel! -Fou'ndatio'nProperty Line �-- A - ` LEACHING LINE No. & Length of lines I`- 'A3 ;otol length/size i FILTER BED ❑ Distance to nearest: Wel! Foundation_- __Property Line I SEEPAGE PITS ❑ Depth Size- T Number SUMPS F1Distance to nearest: Well - - Foundation-- - Property Line 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 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 persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. Signed X 90ATitle: Date: 6 4 SAC FOR DEPARTMENT USE ONLY Application Accepted by Date Area 4 Pit or Grout Inspection by Date- t Final Inspection by4$1,-- _ Date 6 Additional Comments: I ❑ Stk 466-67$1 Ll L66 369-301 11 Manteca 823-7104 El Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEEINFO AMOUNT DUE AMOUNT REMITTED CK AT CASH RECEIVED By DATE PERMIT'NO. i + EH13-24(REV. /a 5) ~]Q,V EH 14-26 [ �./ 1 1 r u y S