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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA Telephone 12091 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i (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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. { Job Address / d City Lot Size�� /).( /� PM Owner's Name E/�Address Phone Contractor "� Address �i�`C 7 i "�GVZ " `- I icense No./i 7 Phone,��/�I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ I DISTANCE,TO,NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS E INTENDED USE TYPE OF WELL�` PROS EM 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 F] Other I Cl Delta Depth of Grout Seal Type of Grout _ I 1 Irrigation —_Approx.',Depth I i Eastern' Surface Seal Installed by Repair Work Done ❑ Type of Pumpr H.-P. State Work Done Well Destruction ❑ Weil Diameter Sealing Material Itop 501 G`l Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATIONA REPAIRIADDITION { 1 DESTRUCTION { I (No septic system permitted if public sewer is available within 200 feet.) (�(\ 1 Installation will serve: Residence Commercial_ th'er ' sV �3 Number of living units: Number of bedrooms Character of soil to a dept 3 feet: Water table depth SEPTIC TANK Type/Mfg. Capacity No. Compartments M PKG. TREATMENT PLT. ❑ ~07// r r' Method of Disp�al Distance to nearest: Well Foundation �� - Property Line Z 1 r` — LEACHING LINE No. & Length of lines � –` Total length/size I FILTER BED ❑ Distance to nearest: elft Foundation Property Line SEEPAGE PITS Depth ZS Size _ Number ; SUMPS ❑ Distance to nearest: Well Fdundatiori – R Property Line DISPOSAL PONDS ❑ 1 7 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:'; w 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." nye The applica m c fo all inspect' n Complete drawing onpver e,siide. f� Signed Date: FOR DEPARTMENT USE ONLY Application Accepted by Date ' Area49:7) Pi or Grout Inspection by ; Date/d' Final Inspection by Date Additional Comments: v f r / t EI Stk 466-6781 ❑ Lodj 369-3621 El Manteca 823-7104 'El Tracy"'835-6385 Applicant - Return all copies to: Envirorimental Health Permit/Services'1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEEAMOUNT DUE AMOUNT REMITTED. CK RECEIVED BY DATE PERMIT'NO. INFO F CASH . I +.(iH 1324 IREV.I/x 51 97;2; EH 14-2e