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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA �12 f !� Telephone (205) 466-6781 PERMIT EXPIRES 7 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. �[ Job Address 90 V 2- A L Ci ��L. ot Size � QAC cu be [ PM Owner's Name Address _P&30 ��/ _ Phone r Contractor's Name _CI-4M ZE4( Li se No. TYPE OF WELL/PUMP: Phone NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLA I SYSTEM REPAIR El H R1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ DISPOSAL FLD PROP, LINE: FOUNDATION AGRICULTURE WELL OTHER WELL 'S PITS/SUftrIPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFI TI / e--� ❑ Indu l ❑❑ Op�en Bottom ❑ Manteca Dia. of Well Excavation _ / 'a omestic/Private u'Gravel Pack Dia. of Well Casin 0 ❑ Tracy Type of Casing ^ �• "`�� Specifications �/Z ❑ Public L1 Other ❑ Delta Depth of Grout Seal ❑ irrigation DepthType:of Grout ---Approx. u�Eastern Su ace Seal Installed by Repair Work Done ❑ Type of Pump � H p _ State Work Done / A/� WWII Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501) TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is Installation will serve: Residence Commercial_ Other available within 200-feet.) Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth r E3 PKG. TREATMENT`PLT. SEPTIC TANK LJType/Mfg Capacity No. Compartments ❑ Method of Disposal Distance to ne9rest: Well _ Founclation-w. Property Line LEACHING LINE ❑ No. & Length of lines T Total length/size FILTER BED Q Distance to nearest: Well Foundation Property Line SEEPAGE PITS ID Depth Size Number SUMPS p Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ !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." Contractors 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 applic t m st r al s tions. Complete drawing onpre sidd /� Signed �+`f• � J ,�i 9 � Title: �� ....` Date: 7 V /� FOR DEPARTMENT USE ONLY C Application Accepted by AII' ` Date�dU Ara 0 // Pit rout peciion by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 0 Manteca 823-7104 L1 Tracy 8355-6385 Applicant- Return all copies to: Environfnenxai Health Permit/Services 1601 E.-Hazelton Ave., P-0. Box 2009, Stk., CA 95201 FEE gMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO CASH +EH t324(REV.101gi1 IR4+`3 ` a EH 1426 o a��/ �'s4-13 xq