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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ' �, f f 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 _ .Local Health District. Job Address N — City Ace4 M P— Lot Size �+ A C PM ; Owner's Name IN C S�� 14 � Address L,pa Phone 7c' 1 Contractor -Q——V Oe Address License No. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUC N ❑ PUMP INSTALLATION ❑'-t- SYSTEM REPAIR OTHER 4X DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. -- P. LINE FOUNDATION _ AGRICULTURE WELL OTHER WELL PITS/SUMPS l INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial El Open Bottom 11 Manteca Dia. of Well Excavation, Dia. of Well Casing-—=— 1 I] Domestic/Private 171Gravel Pack ❑ Tracy Type of Casing Specifications 1`1 Public F1 Other C-I Delta Depth of Grout Seal ✓' Type of Grout ki I I Irrigation --Approx. Depth l l Eastern+ `Surface Seal Installed by; Repair Work Done ❑ Type of Pump H.P. State W/ rk.Dcine ftof u,16' hMV 7- f-114 M T I Well Destruction F1Well Diameter Sealing Material Itop 501 SAt'i�c J,pv�'�orl A� Depth Filler Material]Below 50'I -- i TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I 1 DESTRUCTION I l INo septic system permitted if public sewer is ,. available within 200 feed Installation will serve: Residence_ Commercial_ Other i r of living units: Number of bedrooms Character o to a depth of 3 feet: W (� SEPTIC TANK Type/Mfg No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Dist nares . Well Foundation Property Line r . LEAC NE ❑ No. & Length of lines Total length/size II LTER BED ❑ Distance to nearest: Well Foundation Property Line ^Y SEEPAGE PITS 11 Depth Size Number SUMPS 0 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 s 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 componsa- tion laws of California." � — The applican ca r all require ns. Complete drawing on re arse side. Cy Signed Title: O- Date: FOR DEPARTMENT USE ONLY �7 ! r} f Application Accepted by ` Date 'v f�]� v Area Pit or Grout Inspection b Date Final Inspection by C_l0��f4 1-d Date / Additional Comments: 7 P; ElStk 466-6781 ElLodi 369-3621 ❑ Manteca 823-7104 [3 Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.0!fBox 2009, Stk., CA 95201 �4 £ FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH ♦ EH13"241REV.Iin5l EH 14-28 .•JJJ !!! - - rA