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1-4 APPLtC~ ION FbR•PERMIT` - ` SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL I ON AVE., STOCKTON, CA Telephone (209) 466-67$1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) .} a . 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 C 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. p^ / ) (� Job Address N�(!(� ��_��w T 00 City Lot Size PM Owner's NameY" Address 0 L U 'Phpne i Contract � C3L �� Address 7/ 7 ' License No.�M'22 (" Phone -Gf TYPE OF,WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ r PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC-TANK SEER LINES DISPOSAL FLD. -PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS IN INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS a ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1 ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by G Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAI ADDITION RK DESTRUCTION ❑ (No septic system permitted if public sewer is "�'• f available within 200 feet.) Installation will serve: Residence_ Commercial d Other !r ---Number-of-Iiving-units:---- - -Number-of b rooms Character of soil to a depth of 3 feet: .)44 Water table depth SEPTIC TANK __❑._Type/Mfg ( -Capacity _ No. Compartments_ } PKG. TREATMENT:PLT• ❑ ' Method%6-f Disposal Distance to nearest: Well FoundationProperty Line� LEACHING LINE ❑ No{& Length of lines _ .Total length/sized , Flj(ER BED ❑ Distance to nearest: Well i Foundation I Prop rte y Line SEEPAGE PITS I Depth Size —Number SUMPS ❑ Distance to nearest: Well Foundation roperty Line DISPOSAL PONDS---TO----•-- ----- 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." {- J The applicant �tll for all uir d inspe -cti o ns; Complete drawing on revers ide. Signed 1TrtIe: 71 Date: ! FOR DEPARTMENT USE ONLY Application Accepted by Date ✓ Area Pit or Grout Inspection by Datec'3/ Final Inspection by Date Additional Comments: ❑ Stk 466-6781 odi 369-3611 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all cope to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. + EH13-24(REV.i i e sl 3/i ^6q E,7 FH 1426 O C7caL1W