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APPLICATION FOR PERMIT. SAN JOAQUIN LOCAL HEALTH DISTRICT �i 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 j PERMIT EXPIRES TYEAR 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. I I! Job Address lco GS` I4w4rN A.."-C City k ' ejir _ Lot Size f AC 0L-r" PM Owner's Name`�_Mf5 �(c'�'�/b�/'�l t'j�w„A Address AW61fa A%Zt L� c1�x Phone c _ _3T 6d I� Contractor �W ® Address License No. Phone III. TYPE OF WELL/PUMP: NEW.WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLA_TIONx❑ SYSTEM REPAIR ❑ OTHER ❑ 4 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 1 a FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE _ TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS - - .� _. .. ❑ Industriahe t El Open Bottom ❑ Manteca Dia. of SWell Excavation Dia. of Well Casing II ❑ Domestic/Private ---4 ❑'Gravel Pack ❑ Tracy Type of#Casing Specifications ,I FI Public L1 Other ❑ Delta Depth of Grout Seal Type of Grout I I IrrigationApprox. Depth t 1 Eastern Surface Seal Installed by - I II Repair Workone 111 Type of Pump} - H.P. ! I State Work Done_ p �• � Well Destruction �ElSealin Well Diameter 4 g Material Ito 50'1 Depth ,Filler Material (Below 501 ' ii TYPE OF SEPTIC WORK: NEW INSTALLATION I I FEPAIR/ADDITION t I DESTRUCTION l (No septic system permitted if public sewers { j - I ailable within 200 feet.) !f` 4 1 d Installation will serve: Residence's Commercial e= Other 1 ' Number of living units: r Number of bedroomsf. it Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ ` Method of Disposal p Distance to nearest: Well i Foundation Property Line g j. 4,. � •` =I LEACHING LINE ❑ No. & Length of lines + + Total length/size I! FILTER BED' ❑ Distance to nearest: Well '' Foundation Property Line J l SEEPAGE PITS I I Depth Size t _ Number SUMPS Ll Distance to nearest: Well - Foundation Property Line DISPOSAL PONDS ❑ jl 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, I 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." +i The applicant must call for all required inspections. Complete drawing on-reverse side. 1 II�;0 Signed X .� e,,�,, Title: ti' u41`"f'E-41 Date: ii _ FOR DEPARTMENT USE ONLY'° ` / 4 Application Accepted by14 Date ' - Area&` pp Pit or Grout Inspection by Date Final Inspection by Date d' Additional Comments: ❑ Stk 466-6781 ❑ LoK369-3621 369-3621 ❑ Manteca 823-7104 �❑ Tracy 835-6385 Applicant - Return all copie to: Environmental Health Permit/Services 1601 Ei. Hazelton Ave.,.P.O. Box 2009, Stk., CA 95201 ( FEE AMOUNT DUE AMOUNT REMITTED CK ' RECEIVED BY DATE PERMIT•NO. il"! INFO CASH + EH 13-241REV.�ies1 Se-_ I-T a I EH 14-26 r / i