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l APPLICATION FOR PERMIT I _ SAN JOAQUIN LOCAL HEALTH DISTRICT j 1601 E. HAZEL T ON AVE., STOCKTON, CA I =ephone (209) 466-6781 PERMIT EXPk VYEAR FROM DATE ISSUED (Complete in Triplicate) I 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 o. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. 9- j A,1, y OY% 7-3"rlC � �ifQU Job Address City City Lot S, aPM C1 Owner's Name Address ko I a Z 7 Phone t-_7579- -1 Co A W Address 1, GI-1License No. 7 Z� Phone CT-�/ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ 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 ❑ Gravel Pack ❑ Tracy Type of Casing Specifications r Public t_7 Other ❑ Delta Depth of Grout.'Seal Type of Grout 4 I i Irrigation _Approx. Depth I 1 Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H,P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50'). k Depth Filler Material iBelow 50'1 ` I TYPE OF SEPTIC WORK: NEW INSTALLATION I. REPAIR/ADDITION I I DESTRUCTION I 1 Mo septic system permitted if public sewer is u} i '. available within 200 feet.) ` Installation will serve: Residence X Commercial_ Other 5 � r Number of living units: t Numbe of b drooms ✓ I \kAb Character of soil to a depth of 3 feet: Water table depth t SEPTIC TANK L*l-Type/Mfg Capacity A 6Q O No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well �'G Foundation/_11Q Property Line LEACHING LINE 0- No. & Length of lines F l '° L4 ` ' Total length/size Q K FILTER BED ❑ Distance to nearest: Well_LQ Foundation 0' Property Line SEEPAGE PITS fK Depth Size _ ,� Number _✓ t SUMPS L Distance to nearest: Well 1 , Fo ndation 1 C�f _ Property Line 5 DISPOSAL PONDS ❑ r I hereby certify that I have prepared this application and that the work willrbe done in accordance with San Joaquin county ordinances, state taws, and rules and regulations of the San Joaquin Local Health•Disteiet.i � Home owner or licensed agent's signature certifies-the-followinga;�l certify that in the performance of the work for which-this permit is issued, I shall not I 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 st call fo req ired inspections. Complete drawing on reverses i Signed X cxF"� �'�-Tile:"��..w � � Date: 0c91i'1 aA. W FOR DEPARTMENT USE ONLY Z Irkit i Z�- f7 ,;,-e�A,pplication Accepted�by - J Date Area or Grout inspection by `Date? ��'� ��y�4inal Inspection by Date _1 Additional Comments: ❑ Stk 466-6781 17];L-odit-369=3621 410-Manteca 823-7.10.4:- 0 Tracy,,41EI215-085 Applicant- Return all copies to: Environmental Health P6r-m 2l$eivices f601 E`Hazelton Ave., P.O. Box 2009, Stk., CA 95201 a FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY !.,-,-,DATE PERMIT'N4. INFO CASH t EH 13-24(REV.5�n 5) /2 EH 14-28