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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i (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. Job Address 532 �� ` /- 46��.d f� City "` Lot Size. PM - _ I Owner's Name � t�t -? iddress `fid[� a Phone /�yy Contractor Address�l�. f�{;/ _ License No. +�Phone TYPE-OF WELL/PIJMP:"--NEW-WEL'L❑- `"`"WEL REPLACEMENT E] " " - DE$ RIJCTIO ❑ i f PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER El DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.E PROP. LINE j FOUNDATION AGRICULTURE WELL OTHER WELL r PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFIdATIONS ❑IndustrialQ° pen ottom ❑ Manteca Dia. of Well Excavation ' Dia. of Well Casing s i ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy e 11 Type of Casing c Specifications ❑ Public }}• " ❑ Other ❑ Delta =. Depth of Grout'Seal a F Type of Grout 0 Irrigation g f,o_-.___ Appfox. Depth O"Eastern } Surface Seal Installed by -- i Repair Work Done ❑ Typ of Purmp � �Qq*H.P� � fs. State Work Done � Well Destruction ❑ Well DiameterSeaiingate�.iai (top=50)- -� -__ k-1 r. j Depth �,Iler Materia f elow 50') TYPE OF SEPTIGWORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (Norseptic-system permitted if public sewer is ° I F available within 200 feet)_----4 zvi4 :v O Installation will serve: Residence 4----�Com mercial_f% OtFieri !Number of living units; 4— Number'of bedrooms ? Character of soil-to.a.depth of-3_fe0t: -.4,/✓ki gZter table jepth `Q SEPTIC TANK El •Type/Mfg t '�l ;f i Capacity - i No�Compartments PKG. TREATMENT PLT. ❑ N�lettiod of Disposal Distance to nearest: Well_ """Foundation ^-' Property Line-- r i LEACHITOi"LINE No&Ltngth of lines` F Total length/size ; �! FILTER ABED : Q "`Distance to nearest 'CWell.�!'J Fiiundation ^ `3 - . : Property Line I SEEPAGE PITS ❑ Depth �O b-� Size Y Number j t e} jti SUMPS. Distance to nearest:;J r Well Foundation Property Linel DISPOSAL PONDS ❑ ; 6E hereby certify that I have prepared this application and that the wo&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 he performance oflthe wak:for which this permit is issued, I shall not employ any person in such manner as to become subject to woikman's compensation)aws of California "Conftact&s hiring or sub-contracting signature Ib. Certifies the following: "I certify that in tete performance of the work for which this permitiiiis issued,I shall employ per'sons subject to workman's compensa- tion laws of California The applicant must call foredxins ctions. Complete.dfawing`onnrreverse side. f /r t I Signed X Title: �` -� _..' Date: I FOR DEPARTMENT USE ONLY Application Accepted by - *.h Date / _.€ _ Area a l ,� s I� Pit or Grout Inspection by Date Final Inspection by Additional Comments: t ❑;Stk 466-6781 _ ❑ L&Ji 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8355-6385 icr . Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave.,'P.O. Box 2009, Stk., CA 95201 ` FEE AMOUNT DUE_,_ :..AMOUNT REMITr•ED� D� K--.�- RECEIVED BY - " DATE"r""- ""PERh/l17"NO. V` INFO'."" CASH _� ,..a,,,.,z-,�- ......�_...,..., ,.,,.......,......._�.w.,�,._.,....,�..,.,,.tee +-+'------^�-: ,v:«:.. - .:..._.:z.�;-.-�....�-.-•-.r+--.� .... ., .. ^•.5-.r•-..•----'!'�:---+i-....sw. -v.rr...�,-.,,..� i� _ LI -3 + EH 14-241REV.tist 5l ��- /yx� �O EH 1448 � (® I r