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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED I° (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 i 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 7 SCS /30&J_'� !�D City 406:✓�,?TWUZ' Lot Size ..n PM i Owner's Name G/ Address Phone •36?-.536 Z I' I Contractor FLO / -- ;�7�JDc�2 Addiess -7 Al. No. Phone 9 7 I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS K f[ INTENDED USE TYRE-OF WELL-=— PROBLEM AREA.. CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 1 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications j 17 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ---'-- I i Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by t Repair Work Done ❑ /Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') O s Depth Filler Material (Below 50`) k TY E OF SEPTIC WORK: NEW INSTALLATIONK REPAIRIADDITION 1 1 DESTRUCTION I ] iNo septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Qther Number of living units: Number of bedrooms i Character of soil to a depth of 3 feet: 04A.) Water table depth SEPTIC TANK L� Type/Mfg Capacity /4®P No. Compartments ' `L PKG. TREATMENT PLT. ❑ Method of Disposal 1 Distance to nearest: Well ��"r Foundation /O Property Line 7�✓ LEACHING LINE 11 NO. & Length of lines*e � � Total length)size FILTER SED ❑ Distance to nearest. Weil /d1�� Foundation 2s� Property Line /1 SEEPAGE PITS Depth iyS Size�Z R� Number, SUMPS Cl Distance to nearest: Well ZZW- - Foundation- _ 4, ,_.-._ Property Line -2 i 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 t 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: 1 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 tali for all required inspections. Complete drawing on reverse side. Signed X Title: a7p,� Date: £FO NT USE ONLY ;;11 Application Accepted by C r.. k _Date- V Area 1 Pit Grout Inspection by �1�, Date `7 Final Inspection by Date I ' � �- 1� t { Additional Comments: 0, ' A_ �r kc- Ill `t.fC 2- 1,PC;r 1t 4l✓�e S, �Fi Pj iw. rN5 b ra , J��ZrS1tfb 1 - - ❑ 8-W-466-6781 L7 Lodi '369-3629 ❑ Manteca 823-7104 � O Tracy 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 CASH ^7 a.EH13241REV.I/R5S EH 14-26 v��