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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA 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 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. �J/� �►�' /�� /` Job Address �D �J[.GUJ�'� City 1090%2 l Lot Size / ��' PM Owner's Name _/f ,►Y) � . Address �`! ' � f—incl Phone Contractor 4 Address f 2&aS I c�f6 C Our!/License No. 0_4$2__'21Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ r DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE _ 9OUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ 4 INTENDED USE STYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial E! Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications t f'1 Public Li Other R Delta Depth of Grout Seal Type of Grout—.--. I I Irrigation Approx. Depth 1 1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ �! Well Destruction ❑ Well Diameter Sealing Material atop 50'1 f Depth Filler Material (Belo TYPE OF SEPTIC WORK: NEW INSTALLATION I'1 REPAIR/ADDITION IV DESTRUCTION I 1 JNo septic system permitted if public sewer is ---available within 200 feet.) Installation will serve: Residence_ Commercial_ Other ` Number of living units: Number of ooms - _�� 5 j Character of soil to a depth of 3 feet: .tt Water table depth !� \ SEPTIC TANK , Type/Mfg IV I G y0- Capacity No. Compartments PKG. TREATMENT PLT. ❑ij Method of Disposal Distance to nearest: Well�� Foundation Property .Line Q LEACHING LINE No. & Length of lines ` Total length/size FILTER BED ❑ Distance to nearest: Well `'' 3�� FouAdatibn_ ] Property Line 361 i SEEPAGE PITS J !fy Depth iize. �! Number �!'� SUMPS ❑j Distan e;to neare_'st'L-�-Well1_" .r_ F ndation �^d P Property Line DISPOSAL PONDS 1 ❑ ' "r w1 f I hereby certify that I have prepared this application and that'6e wdrrk will b'e�done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of"'the j an Joaquin Local Health Diltrict. Home owner or licensed`agent's signature certifies the following: "l 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." Contractors hiring or sub-contracting signature certifies the following: "I cartify 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 ust call for all r uired inspections. Complete drawing on reverse side. Signed X_ I Title: 60-),k Date: 7-1f U+ FOR DEPARTMENT USE ONLY Application Accepted by Date r Area 12- Pit 2Pit or Grout Inspection by i Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781---- - M—6d't--369-3621- (�l-Manteca-••823-7184---- -❑.Tracy` 835=6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton.Ave., P,..O. g4j,2909, Stk., CA 95201 FEE i CK f INFO AkliOUNN�3T(�DUE AMOUNT REMITTED C SH RECEIVED BY DATE�7(� PERMIT�N[O.J i.£H14-2B(REV.k/H51 vf!' �. I�l� / ,� / �QV 1