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;.: APPLICATION FOR PERMIT _. SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED 11 (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 ® e- A ✓s— City Lot Size 15372V PM Owner's Name k 2c,. Address •a'�PV2 �`4 '� Phone ` Contractor e /Address 201r7 � License No./Phone -eq TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 r ❑ Domestic/Private ❑ Gravel Pack: ❑ Tracy Type of Casing Specifications r-1 Public ❑ Other1. Cl Delta Depth of Grout Seal Type of Grout _ I I Irrigation Approx. Depth i I_Easterr) Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter? Sealing Material (top 50')_ v� Depth f' Filler Material I8elow 50'1 4 TYPE OF SEPTIC WORK: NEW INSTALLATION? REPAIR/ADDITION [ I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet ) ' .f Installation will serve: Residence Commercial Other �}\ Number of living units: Number of droonr Character of soil to a depth of 3 feet: .! ` Water table depth SEPTIC TANK Type/Mfg �,r Capacity No. Compartments PKG. TREATMENT PLT. ❑ i t t Method of Disposal Distance to nearest: Well Foundation _t`+ Property Line 2 LEACHING LINE No. & Length of lines b L `Totaf length/size f� �C 1/2- I FILTER BED ❑ Distance to nearest: Well� ,Foundation Property Line SEEPAGE PITS X Depth Size'. Number SUMPS L1 Distance to-nearest: Well Foundation Property Line S � 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 Di§trict. - 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,.) shall not employ any person in such mariner as to become subject tp'woTk"man's compensation taws 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." "" r l The appiin all i actio s. plate drawing on r arse side. Signed X 14 � - Title: _(l�'�z/'-os'[ ��''� Date: � f FOR DEPARTMENT USE ONLY Application Accepted by 6P / ) Date Area it r Grout Inspection by Date% Final Inspection b Date�,Q 4 4 Additional Comments: I ❑ Stk 466-6781 ❑ L i 369-3621 ICi,❑ ManteC& 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 FEE AMOUNT DUE AMOUNT REMITTED " CK RECEIVED BY DATE PERMIT'NO. f INFO - p CASH � +.EH 1114-4-28 241REV.tinsi EH '#_s _C /7 ! 9 ��V/�Cyy i!