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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 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. _Ff'} /� Job Address —l� S Q�/ �' City Lot Size a Gr PM Owner's Name 61L ` Address ! q 0)S * Phone " trb (300 �.n. . ttom�.. Contractor��u")�` � �rU�d�r�ss�` Z .fes PM4 dI f� License No. q_�y'4Z Phone_ �7 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ r ; PUMP INSTALLATION, I` SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK- SEWER LINES DISPOSAL FLD. --PROP-...LINE w--— - f ` FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS X41 I I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 4 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing rJ❑ Domestic/Private ❑'Gravel Pack ❑ Tracy Type of Casing Specifications f"1 Public n Other Ll Delta Depth of Grout Seal Type of Grout I I irrigation u _.-Approx. Depth l I Eastern Surface Seal Installed by _tet Repair Work Done ,❑ l+ Type of Pump, H.P. State Work Done_ Well Destruct6h t ❑ Well-Diameter Sealing Material {top 50'1 1_____0epth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIRIADDITION [ „ DESTRUCTION I I (No septic system permiffed if public sewer is / available-within 200 feet.I Installation will serve.- Residence'_ Commercial Other 'f Number of living units: 1,5�_ ;'Number oft 'roo s ✓ - //�� Character of soil to a depth of 3 feet: O Water table depth SEPTIC TANK f Cl' Type/Mfg Capacity No'Compartments . PKG. TREATMENT PUT�� Met tl of Disposal Distance to-nearest: Well Foundation Property-Line LEAC _ E L1 No. & Length of lines �- f Total length/size -� i r, x ! .. 1LTER �GDistance to'nearest: Well Foundation $�� Property Line f"10 M SEEPAGE PITS { I" Depth'_ Size Numberr SUMPS Distance to nearest: Well Foundation Property Line �{ DISPOSAL PONDS/ ❑ 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 Local Health District. �k Home owner or-licensed agent's signature certifies the fallowing: "I certify that in the performance of the work for which this permit is issued, I�T�shall not employ any person in such manner es to become subject to workman's compensation laws-of-California.'"Contractor's hiring or sub-contracting signature _ certifies the following:21-certify that in the performance of the work for which this permit is issued„I's`hall employ persons subject to workman's compensa- tion laws of California." r The applicant must call r required inspections. Complete drawing on reverse side. -� Signed Title: ctiItiG1 fJ"4� Date: IC I& 7 R DEPARTMENT USE ONLY '• Application Accepted by Date ®�^ 'Area r Pit or Grout Inspection byDae Final Inspection by, ; Date �.. Additional Comments_: u❑ Stk 466-6781/ ❑_L"—j69-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant ; Return-, !urncopies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEET AMOUNT,DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO CASH .,EH 4 IR[V. EH 14-2