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APPLICATION FOR PERMIT SAN JOAO,UIN,,LOCAL HEALTH DISTRICT 1601 E. HAZE.T dN AVE., STOCKTON, CA Telephone 12091 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. Job Address At . City Size PM ---� Q�—rcv- —.. �:. Owner's Name . l Address 5G Phone Contractor � c7 Address License No.3/ MI�b Phone F TYPE OF WELL/PUMP: NEW WELL ❑ _ WELL REPLACEMENT❑�A.�'._"_DESTRUCTION,_❑r.., r___----• i PUMP INSTALLATION ❑__ "" i --SYSTEM REPAIR ` OTHER ❑ ` DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. I 1 PROP. LINE d FOUNDATION AGRICULTURE WELL OTHER WELL t.PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I ❑ Industrial ❑ Open bottom LJ Manteca Dia. of Well Excavation Dia. of Well Casing f Domestic/Private ❑ Gra4elPack El Tracy Type of Casing Specifications _ O Public ❑ Other t ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth. ❑ Eastern Surface Seal Installed by 1 l Repair Work Done Type of Pump H.P. State Work Don G Well Destruction ElWell Diametei"r Sealing Material (top 501 Depth Filler Material (Below 501 1 j I TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system`.permitted if public sewer is (/ available within 200 feet.] Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms { Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ r Method of IDisposal l Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines M t T Total length/size i I FILTER BED . ❑.. Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number 3 } SUMPS ❑ Distance to nearest: Well Foundation r-Property Line t 1 " DISPOSAL PONDS ❑ 1l I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin cduntyf rdinances, 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."Contractor's hiring or subcontracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued,I shall employ perso61subject to workman's compensa- tion laws of California." ,� ti �' Tj ; = _ E Thea st call f19,/V�, or all r fired i pettion , omplete�dawirig;oD r _si i:..t._--n1_11- -- -T- r ; Signed X c 3= Title: 1 FeS ;Da6te: FOR DEPARTMENT USE ONLY Application Accepted by Date -- Area L I I -�-� r , Pit or Grout-Ins b �• f `.Date Final Inspection by Date l c Additional Comments: llStk 466-6781 LlLodi 369-3621 L] Manteca 823-7104171Tracy 835-6385 Applicant-Return all copies to: Environmental Health Permit/Services 16 E. Hazelton Ave., P.O. 01: Box 2", Stk., CA 95201 INFO AMOUNT DUE AMOUNT REMITTED ASR RECEIVED BY DATE PERMIT'NO. iEH 13-24 1REV.-iin51 � 1�-1 EN14-26 ( i