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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL I ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1,YEAR FROM DATE ISSUED (Complete in Triplicate) Application is he[eby 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 1/moi(n Y-11✓l w 1 City Lot Size PM Owner's Name ��'1 PrP- 0,*-Xd S Address 2)D9l M'+ 0IablO 8 \IC ' Phone CC �7 P611oA 1+0 �'_2 -7 64 Contractor DYi t t i Ad�ess P-o• PX�X �� I License No.d�".� hone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION C ® J PUMP INSTALLATION ❑ SYSTEM REP9IR ❑ OTHER CC] DISTANCE TO NEAREST: SEPTIC TANK ;;"600— SEWER LINES >500 DISPOSAL FLD. nOhe r'ROP. LINE FOUNDATION 'Y1001 AGRICULTURE WELL Uoine--OTHER WELL_JOILreITS/SUMPS -ial1V1-, INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS a/r El Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 1510 Domestic/Private ❑ Gravel Pack 11 Tracy Type of [ng�VCf �� Specifications 1 Public her 1�,LDelta De of Grout Sell %0-P5 Type of Grout — l4 r ` I}r�nyy�au�n S�.Approx. DepW`Tf��Jt�cn� �: urface Seal Instal l�d by fiY�WI lfi � � - Repai� '. ork Done C, Type of Pump e H p�_ \\\6kate Work Done Well Destruction ❑ Well Di eter Sealing Material (top 501 re •��JS'� DeptFiller Material (Below 50'1 l✓ '3�' �p. — TYPE OF SEPTIC WORK: NEA INSTALLATION X REPAIR/ADDITION I I DESTRUCTION i (No septic sy!Nem permitted if public sewer is available within 1`Z100 feet.) Installation will serve: Residence\v Commercial_ Other Number of living units: Number_of bedrooms 1 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 Distance ton rest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of I es Total length/size FILTER BED ❑ Distance to nea Well Foundation Property Line SEEPAGE PITS I I Depth �A .; Size Number SUMPS ❑ Distance to nearestWell Foundation erty PropLine DISPOSAL PONDS El I hereby certify that I have prepared this appfill6lion and that the work will be done in accordance with San Joaquin county ordinaAces, state laws, and rules and regulations of the San Joaquin Loc4l 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 perin[t 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 pert-#mane of the work for which this permit is issued,I shall employ persons subject t workman's compensa- tion Taws of Ca' rnia.' !1 The applic t st call fad all re Gired i i Complete drawing on reverse side. w Title: Date- Signed F R DEP TMENT USE ONLY (� Application Accepted by Date _ Ar /�✓` c _ / Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823 C1_Tracy 835-6385 - � ... Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, St ., 95201 IFEE NFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. + EH 13.24 1REV.„n 5) ,c0 �"� 1 r 1 rte, I �^ EH 1428 I- 000