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' APPLICATION FOR PERMIT SAN JOAQUIN-LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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. Ole � City Lot Size PM Job Address 50% �1A0/� P _G -O 7 L.? C� Address _ o ± Owner's Name Phone� - PLL Contractor �� Q Address License No. 9"•Z� Phone 3wt7pp 15Im j TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ; PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ f 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 0 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack D Tracy Type of Casing Specifications, FI Public (❑ Other ❑ Delta Depth of Grout Seal Type of Grout _- 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 ❑i Well Diameter Sealing Material (top 501 Depth Filler Material (Belo ') -- TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIRIA)DITION [Or DESTRUCTION l I (No septic system permitted if public sewer is Q � available within 200 feet.). Installation will serve: Residence WWI' Commercial_ Other Number of living units. Number of edrooms Character of soil to a'depth of 3 feet: • Water table depth /00 i SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. D f` Method of Disposal 'Distance'to nearest: ; Well Foundation Property Line LEACHING LINE LeeNo. & Length of lines Total length/size 1 'FILTER BED 'D Distance to-nearest: - Well Foundation f Property Line SEEPAGE PITS 1*---Do pth f Size i - Number 'SUMPS ❑ Distance to nearest: �'�' Well_lt Foundation �d 1 Property Line 7 -- DISPOSAL PONDS ❑ ' , A "IA 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. ; I - 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, l 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.:' f The applicant must call for all reqdireclPspections. Complete drawing on r verse side. Signed X Title: � �+ _ Date: FOR DEPARTMENT USE ONLY s Application Accepted byA"-) w\� *�s x _ Date �1110-14e-) Area or Grout Inspection by 1>y1'1 I�prtG bate j Uj Final Inspection by�) �1i�1� Date ?r1 6 O Additional Comments:' Comments: D Stk-_466.6781...-. ;-Q-Lodi--369.3621.-0 Manteca-823-7104 —C9 Tracy-836-6365 Applicant - Return all copies to: Environmental Health Permit/Services 1601..E..Hazelton Ave., P.O. Box 2009, Stk., CA 95201 CKs FEE AMOUNT DUE AMOUNT REMITTED A RECEIVED BY DATE PERMIT'NO. INFO CASH `-0 } 1 +.EH 13-24 IkEV.1/H sf `7o 1 V1� p CT.—1 } EH 14-28 �O