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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 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 _Z9e �1L- Lcity �TinC Lot Size Q ®G" PM Owner's Name �ff}115 /�i'Q>'f Address Phone ` Q Contractor's Name I.e�15W&1 & V CW'.( License No. Phone _X Z P rrt ur- Wtiurunnr: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ REMITTED PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 5 DISTANCE TO NEAREST: SEPTIC TANK SEINER LINES DISPOSAL FLD. PROP. LINE `�-� FOUNDATION _ AGRICULTURE WELL OTHER WELL"_- PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS • o } ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/ Private ❑ Gravel Pack k ❑ Tracy Type of Casing _ Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout— rout❑Irrigation El Irrigation „Approx. Depth ❑ Eastern Surface Seal Installed by; Repair Work Done ❑ Type of Pump + H. P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 r Depth , I Filler Material (Below 501 I trt Ur btrilc WORK: -NEW ILLPT NSTAION ❑ REPAIR/ADDITION DESTRUCTION © (No septic system permitted if public sewer is ✓/, available within 200 feet.) Installation will serve: Residence — Commercial _ Other r Number of living units: -4— Number of .bedrooms Character of soil to a depth of 3 feet: C L ,y i Water table depth- SEPTIC epth_SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line l f. LEACHING LINE i No. &`Length of -nes _% �%[� Total length/size_ 1 ]C _4 FILTER BED ElDistance to ne'ares't: Well Foundation Property Line y � 6 SEEPAGE PITS SUMPS`��> DISPOSAL PONDS Depth' ,_.: El:. Distance to nearest: ❑ Well Number Foundation Property Line 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 Caliifornia." 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 app lic st.call for allMquired in Complete drawing on reverse' A. Signed Title: Date: _ FOR DE T NT USE ONLY Application Accepted by - Date Pit or Grout Inspection by t -� Date Final Inspection by Additional Comments: ❑ Stk 468-6781 ! ❑ Lodi 369-3621 J- ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 + EH 13-24 (REV. 10183', EH W28 FEE INFO AMOUNT DUE iAMOUNT REMITTED CK CASH RECEIVED 8Y DATE PERMIT"NO. ' `�-� S�Srg • o } Sf-l_lS�ld