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v �s APPLICATION,FOR PERMIT r SAN JOAQUIN LOCAL HEALTH DISTRICT www 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES) YEAR FROM DATE ISSUED ' ;r (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. I Job Address 'd/ City 6716Cxr1-v7y Lot Size PM 4 _ Owner's Name Address .5 fI 7_ R1514T S1-- Phone 1A 6 7�1- 7 Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATI SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK S ES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE OTHER WELL INTENDED USE TYPE OF WELL PROBLEM AREA CONSTR CATIONS ❑ Industrial ❑ Open Bottom Q Mante ia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack Tracy Type of Casing Specifications ❑ Public ❑ 0 ❑ Delta Depth of Grout Seal Typ f Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair W one ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler.Material (Below 501 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 r Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No.'& Length of lines k Total length/size i FILTER BED Fl Distance to nearest:. ( Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number s SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ ; 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 Lcical 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 m st ca11 for all required inspections. Complete drawing on reverse side. Signed Title: �1I 1 Date: FOR DEP TMENT USE ONLY Application Accepted by + Date Area I Pit or Grout Inspection by Date Final Inspection by Date I 41 Additional Comments: moi^' ` ❑ Stk 466-6781 ❑ Loi 369-3621 ❑ 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 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO C + EH 1 -24[REV.1/H 57 g'sO , O CA= EN 144-28 ( 1