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r 4. APPLICATIQN FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ` 1601 E. HAZEL T ON AVE., STOCKTON, CA ?c,, Telephone (209) 466-67$1 . . Y PERMIT EXPIRES 1 YEAR .FROM DATEiISSUED }. ,.(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. S 77 Job Address ,d 't �� eC- City Lot Size PM Owner's Name 02 _V6-Address )C, vvt- e Phone_ CAI Contractor's Name �``U License No. -S �27 C`J� 5-16) Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REP OTHER ❑ DISTANCE TO NEAREST: SEPTIC-TANK- SEWER LINES . ISPOSAL FLD. PROP. LINE " rFOUNDATION AGRICULTURE-WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA __CONSTRUCTION SPECIFICATIONS ❑ Industrial q ❑ Open Bottom., ❑ Manteca Dia. of Well Excavation Dia. of Well Casing �y Domestic/Private LJ Gravel Pack ❑ Tracy Y• Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern 1 Surface Seal Installed by Repair Work Done X Type of Pump ;H:P. State Work Done Well Destruction D. Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑- REPAIR/ADDITION ❑ DESTRUCTION ❑ INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: ' Residence_ Commercial— Other Number of living units: Number of bedrooms I ,G, 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 to nearest: Well Foundation Property Line ! a LEACHING LINE 3 ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth _Size Number SUMPS ❑ 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." k4 The appl"rt call for all requi inspe ions. Complete drawing on reverse side. Signed `- Title: Date: v J/ l t DEPARTMENT USE ONLY (L Application Accepted,by �- - - - _-- Date d-v V Area Pit or Grout Inspection by Date Final Inspection by Datea.,M ed Additional Comments: ❑ Stk-466=6781 -❑.L-odi-369=3521-- -2 Manteca,-823-7104.- --❑ Tracy 835-65§3 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E.Hazelton Ave.-,,P.O. Box 2009, Stk., CA 95201 FEE MOUNT DUE AMDUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. , INFO CASH {� + EH 1324(REV.10l83i � EH 1426 1