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APPLICATION TOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT i 1601 E. HAZE T ON AVE., STOCKTON, CA r Telephone {209} 466-6781 PERMIT EXPIRES 1 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 w 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 Ar City Lot Size PM j Owner's Name -16 Address i , (� !, t Phone A ` " "Ai3iiress "a1' Lic'ehse Nil: V �v-'Phone s, Cantrat for =- _ - _ ll TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 1 > PUMP INSTALLATION❑ SYSTEM REPAIR ❑ OTHER ❑ f DISTANCE TO NEAREST: SEPTIC.TANK SEWER-LINES._ _DISPOSAL FLD. POOP. LINE FOUNDATION - AGRICU TUR WELL OTHER WELL PITS/SUMPS j INTENDED USE TYPE OF WELL PROBLEM AREAONSTRUCTION SPECIFICATIONS x+ I f 1 ❑ Industrial ElOpen Bottom; 173Manteca v Dia.'of•Well Excavation` Dia. of Well Casing , . C1 Domestic/Private ❑ Gravel Pack El Tracy Type of Casing Specifications I. ' l'7 Public 171 Other ❑ Delta Depth of Grout Seal Type of",Grout I I Irrigation _Approx. Depth t I Eastern Surface Seal Installed by it Repair Work Done ❑ Type of Pump h H . State Work Done_ a §I Well Destruction ❑ Weil Diameter ealing Material (top 501 t� ' - Depth x: s---=Filler--Material-(Below-504-- TYPE 50'-1� - - t.} TYPE OF SEPTIC WORK: NEW INSTALLATION;1i1 REPAIR/ADDITION DESTRUCTION I 1 INo septic system permitted if public Sewer is ' } available within 200 feet.i ti.r .' Installation will serve: Residence_ Commeikcial— Other " Number of living units: Number of bedrooms b Character of soil to a depth of 3 feet: Water table depth 4 .tet SEPTIC TANK ❑ Type/MfgCapacity No. Compartments E ' t PKG. TREATMENT PLT. ❑ ` Method of Disposal " - " � Distance to nearest: el ou at on Property.Line i LEACHING LINE ❑ No. & Length of lines Total length/size , �+ FILTER BED ❑' Distance to nearest:, ti Property Line if SEEPAGE PITS I ) Depth~ � Size Number SUMPS Li Distance to nearest: t Well Foundation � Property Line'. IL DISPOSAL PONDS ❑ I hereby certify that I have prepared this'appiication and that the'work will be done in accordance with-San Joaquin county ordinances, state laws, and i rules and regulations of the San.Joaquin Local Health District. A J- L Home owner or licensed agent's signature certifies the following: "I-+tify that in the performance of the work for which this permit is issued, l 'shall not _ employ any parson in such manner as to become'subject.to workmans.e6mpensation%laws-df-Califofnia."'Contractors hiring or sub-cont; I i certifies the following: "I certify that ih thepperformance of th'e work for which this permit is issued, l shall employ persons subject to workman's compensa- tion laws of California." s The applicant must call for req fired inspecti ox s. Complete drawing on reverse side. F i Signed X Title: .-j5E4,,f)!7h,J2e!!!je ° Date: J FOR.DEPARTMENT USE ONLY -__.,,, �• „ Application Accepted by _ Date / Area r4 ._ Oat 6; it r Grout Inspection b / Date Final Inspection by 1-i = Y Additional Comments: �i ❑ Stk 466-6781. -_E)S=odi "369-3621 ❑ Manteca 823-7104 ❑ Tracy 835.6385 i Applicant - Return all copies.to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED C SH RECEIVED BY DATE PERMIT'NO. xt irlEH13-241REV.limb) / P 1EH 14'26 "" ,. ..,.-.-.»... ..-.... _ .«.......U l �C ! + F