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APPLICATION FOkPERMIT— a; � SAN JOAQUIN-LOCAL HEALTH STRICT j 1601 E. HAZEL T ON 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 I Local Health District. ; Job Address / 150 �r a s City Lot Size !O QM�Sf PM �d�esPh'll;p 9saA7 Owner's Name PS 1 6 66 22>� .1►i�'JL� Phne )Z1131XS Contractor _T 14 11 S Address %z 23 "icense No4�J5/�Phone7Z) Tr_3 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ -� PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ' ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing "1:1Domestic/Private Ll Gravel Pack El Tracy—�' - Type of Casing Specifications CJ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation _Approx. Depth ❑ Eastern Surface Seal Installed by 1 Repair Work Done ❑ Type of Pump H.P. State Work Done { i Well Destruction ❑ Well Diameter - . Sealing Material {top 501 Depth Filler Material (Below 501 1 TYPE OF SEPTIC WORK: NEW INSTALLATION, REPAIR/ADDITION ❑ DESTRUCTION ❑ {No septic system permitted if public sewer is `_v\mil available within 200 feet.) Installation will serve: Residence Commercial_ ther - i 1 Number of living units: –_ Number of bedrooms 1 Character of soil to a depth of 3 feet 01/l�P � - Water table depth �.1 SEPTIC TANK .e Type/Mfg Capacity No.' Compartments PKG. TREATMENT PLT- ❑ a Method of/Disposal � p� Distance to nearest: WellA6 8_ Fpundation Property Line f[X) LEACHING LINE e No. & Length of line. 00 Total length/size FILTER BED ❑ Distance to nearest: Well Foundation 95, rr Property Line 40 F�r' SEEPAGE PITS 2' Depth � �T Size Number SUMPS ❑ Distance to nearest: Well Foundation 125 R7' Property Line_}0 i DISPOSAL PONDS ❑ f 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 i 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 subiect to workman's compensa- tion laws of California-" } The applicant or all requ'red inspections- Complete drawing on reverse side. } Q ^] Signed �F Title: - i`lit f Date FOR DEPARTMENT USE ONLY Application Accepted Zby Date k7Area 6 / Pit or Grout InspectioDate^ Final Ins/pAectionbvate T W4— r V -rF•Additional Comments:❑ Stk 466-6781 - 1 ❑ 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 �'*••,"� -N p "AMOUNT DUE AMOUNT REMITTED K 4 RECEIVEDBY/ DATE PERMIT`N1O. 11 1 EH 13-24{HEV.1/H 5th 1� �L �EH 1428 c �