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t APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT R _0 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. 2SS 3g 1 A cru /3?_ City / Job Address � .�. �, f7 � °f !/aT"<?4�!S Lot Size / / �'1`<- PM i /� f Owner's Name Uff��O AQ#/''.S 10im ,l !h'C,Address % �. 8-0X _0y�l l'f�/ ,_5 Z Phone Q 3 7 + I Contractor Ts I Address Zg "( � License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES Sa' DISPOSAL FLD. PROP. LINE T FOUNDATION; AGRICULTURE WELL rJ0 OTHER WELL PITS/SUMPS e �1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS , ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public F1Other F] Delta Depth of Grout Seal X450 Q��T.ype of Grout " t I I Irrigation —.-Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done i Well Destruction ❑ Well Diameter I Sealing Materia! flop 501 Depth Filler Material (Below 501 _ t TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION I ] DESTRUCTION l I INo septic system permitted if public sewer is Iavailable within 200 feet.) Installation will serve: Residence i Commercial_ .Other ! Number of living i units: Number of bedrooms k,\J Character of soil to a depth of 3 feet: Water table depth S SEPTIC TANK ❑ Type/Mfg I Capacity. No. Compartments + PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line' w i LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS i I Depth f Size Number , SUMPS Cl Distance to nearest: Well Foundation Property Line {",V• 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 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 compensa- tion laws of California." The applicant st all for all required 1 spections. Complete drawing on reverse side. / �/fw Signed XVWX Title: _ _ - _ Date: / /V F =T USE ONLY i Application Accepted by Date r -Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 1 Cl Manteca 823-7,104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 # �. INFE AMOIJT DUE AMOUNT EMITTED CASH RECEIVED BY DATE ` PERMIT'NO. +.EH14-211REV.1/x51 cc .,v/ EH 11-29 ��..33 I