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APPLICATION,FOR PERMIT • SAN JOAQUINIOCAI HEALTH DISTRICT 1601 E. HAZE T ON AVE.;,STOCKTON, CA 'Telephone 12091 466-6781 r..r, ,... 5 fit 51' PERMIT EXPIRES (YEAR FROM DATE ISSUED,,, �� ,�, +1. .,; ff•:;, (Complete in Triplicate). ,t.� ,..., ?� t , 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. ,�`" ' " . . o, r: t' Y I Job Address S~ City Lot Size PM :. . . Owner's Name f --1 AddressS*M _T — 'Phone J Contractor _ Address ,0. License No. 3 Phone r D WV SrwA TYPE OF WELL/PUMP: ; NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO N AREST:.SEP I TANK SEWER LINES DISPOSAL FLD._- PROP. LINE ? ''FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ G' INTENDED USE TYPE OF WELL PROBLEM AREX—CONSTRUCTION SPECIFICATIONS 1 [],industrial I 1j,Oi6en Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casi 1g ❑ Domestic/Private ❑ 6avel Pack,kv ❑ Tracy Type of Casing � Specifications ❑ Public t ❑(Ot her r�`` "❑ Delta Depth of Grout Seal � Type of Grout ❑ Irrigation --* O f • .Approx. Depth ❑ Eastern Surface Seal Installed y i Repair Work Done ❑ Type of Pump H.P. State Work Done_ l Well Destruction ❑ Well'Diameter4r"� .4 Uiller�Material-(Below-501— ealing Material {top 50') } Depth �. � J TYPE OF SEPTIC WORK: NEW-,INSTALLATION ❑ REPAIR/ADDITION■ 'DESTRUCTION ■ iNo septic system permitted if public sewer is y �. '� available within 200 feet.l � Installation will rterve'- Res-rderfeee_& Commercial— Ot Tr Number of living units: -4— Number of bedrooms _. -- •�vzs U\ Character of soil to a depth'of Veet: r �. Water tatil�epth �- SEPTIC TANK ! �r,TY13 /,Mfgfss ,.CapaciSO,• jNo:�Go`rriRarCments f l� PKG. TREATMENT PLT. ❑ �, } Method of Disposal V Distance to nearest: Well Foundation—__l0 Property`bne LEACHING LINE ❑ No, & Length of lines ' t Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property tine SEEPAGE PITS ❑ Depth SiT Number SUMPS ;_.._ [J—Distance-to•nearest:•----WWell--n�--Foundation Propeity Line DISPOSAL PON 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. 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." The applicant must call for all required inspections. Complete drawing on r arse side. / Signed X Title: ' Date: L9_3 I-13 FOR DEPARTMENT USE ONLY [ \/ Application Accepted by ` Date-3-31 — Area I� Pit or Grout Inspection by Date Final Inspection by Date L ! Additional Comments: ❑ Stk 466-6761 ❑ L i 369-3621 ❑.Manteca 823-7104 Tracy 55-638,5 �F 1`�q]eY �n d n$ Applicant- Return all copies to: Environmental Health'Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT NO. + EH13-24(REV.I K 5) • .; 7dt� - -. - 3-31-g �a � - - EH 11428 L �