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APPLICATION FOR PERMIT 1�d�y t SAN JOAQUIN LOCAL HEALTH DISTRICTt �J✓'` 1601 E. HAZEL T ON AVE., STOCKTON, CA i� Telephone (209) 466-6781 t p'1 PERMIT EXPIRES 7 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. n Y Jab Address M17: """✓✓✓ r J. City U Lot Size PM Owner's Name Address V yr 47 e,2 a Phone Contractor Address License N Phone PE OF WELL/P MP: NEW WELL ❑ ELL REPLACEMENT ❑ fDESTRUCTION �+ .PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 3b� t DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, OTHER' PROP. LINE FOUNDATION:. AGRICULTURE WELL -OTHER.WELL _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS PITS/SUMPS- ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 13Domestic/Private ❑ Gravel Pack Dia. of Well Casing ❑ Tracy Type of Casing 11Public El ❑ Delta Depth of Grout Seal Other Specifications ❑ Irrigation ---Approx. Depth ❑ EasternType of Grout Surface Sea! Installed by Repair Work Done ❑ Type of Pump H P } Well Destruction ❑ Well Diameter Sealing Material {top 50'1 State Work Done Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is Installation will serve: Residence— CommercialOtfler available within 200 feet) Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK Water table depth ❑ Type/Mfg PKG. TREATMENT PLT. ❑ CapacityNo. Compartments Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines ' Total length/size FILTER BED t ❑ Distance to nearest: Well Foundation Property Line j SEEPAGE PITS ❑ Depth Size SUMPS Number u .._,_ ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS El - - . I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county rules and regulations of the San Joaquin Local Health District. q my ordinances, state laws, and Home owner or licensed ant'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 s c manner as to become subject to workman's compensation laws of California."Contractor's hiring or subcontracting signature certifies the fallowing:' c rti t tin the pert ce of the work for which this tion laws of Cali mia. permit is issued, I shall employ persons subject to workman's compensa- The applicant m cal f r a re uired s ion Complete drawing on rev side. Signed � ' Title: Date: F R DEPARTMENT USE ONLY Application Acce r'' pd by..' t. Date 1 �`" Area d j��&� 1 ,".I Pit or Grout Inspection pateFinal I nspection by Date Additional Comments: ❑ Stk 466-6781 .� Q1 Lpol .369�:1��y�� ;❑.,Manteca 823-7104 ❑ Tracy Applicant- Return eJl jc pii s,to.. EnUr�bflrriialitalsri�>31th Permit/Services 1601 E: Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE l�,✓( INFO AMOUNT DUE AMOUNT REMITTED. RECEIVED BY DATE PERMIT'NO. + EH 13-24(REV.I/6 5) Y' _ EH 1426