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` APPLICATION FOR PERMIT E'S SAN JOAQUIN LOCAL HEALTH DISTRICT No we I0'A2k&oY 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 �w O PERMIT EXPIRES 1 YEAR FROM DATE ISSUED_ 1�� (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�,� City (� Lot Size A�Qt�/ 1 0 + PM Owner's Name OAddress16 7 PhonA I Contractor d f" Address License No. 9�d r Phone 7Y TYPE OF WELL/PUMP: NESOWELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL_FLD. _ PROP. LINE n FOUNDATION AGRICULTURE-WELL"t--_ OTHER WELL PITS LIMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing � ❑ Domestic/Private ❑:Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public C1 Other ❑ Delta Depth of Grout Seal Type of Grout z W ❑ Irrigation �pprox. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P, State Work Done 1 Well Destruction ❑ Well Diameter Sealing Material {top 501 Depth Filler MaterialrfBelow 501 L , TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION �Mo septic system permitted if public sewer is available within 200 feet.' � Installation will serve: Residence._` Commercial— Other � Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ +4■ Method of Disposal Distance to nearest: Well Foundation Property Line f LEACHING LINE ❑ No. & Length of lines .. "" dotal length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑1 Depth Size oOol Number SUMPS �I El Distance to nearest: Well Foundat' Property Line DISPOSAL PONDS. ❑ 1 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.t 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." Contractors 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 must c II for all required 1 e tions, Complete drawing on reverse side. Signed X44<A4Title: Date: —.b�� G LAe F R DEPARTMENT USE ONLY � € n i (�� Application Accepted by IN ate" S� �O" T� --Aie &�_Z01 a '� Pit or Grout Inspection by Date Final Inspection by Date r Additional Comment 6%- C., ¢, — CA ❑ Stk 466-6761 171odi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385'10"moi = ' Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O.'Box 2009, Stk., CA 95201FEE 3 INFO AMOUNT DUE AMOUNT REMITTED CSI RECEIVED BY ^�DATEg� PERMIT�yNO. + EH 14'm(REV.1iAS)