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i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE.; STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in T6plicate) 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 _ _ t'Q is f�t S' R City VAI Lot Size/,TO X pM Owner's Name &,y S Address Phone 6` Contractor L', lia�/,t Address fm License No. Phone f°?� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR LI OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ _ _DISPOSAL FLD. PROP. LINE II� ! FOUNDATION T_ AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C1 Industrial 0 Open Bottom O Manteca `Dia. of Well-Excavation . Dia. of Well Casing i k ElDomestic/Private ❑ Gravel Pack 'LlTracy �' Type of Casing Specifications El Public 0 Other �`' � O Delta� i,— Depth of Grout Seal Type of Grout 0 Irrigation —'-Approx..Depth ❑ Eastern ? \�\Su6ce Seal Installed by i-' Repair Work Done ❑ Type,of Pump r. H.P. State Work Done %Nell Destruction ❑ Well Diameter #"Sealing 4Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is Q� available within 200 feet.) ff 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 I PKG. TREATMENT PLT. ❑ ', ( Method of Disposal Distance to nearest: Well Foundation Property Line , LEACHING LINE o.,& Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well_ O Foundation /f7 Property Line SEEPAGE PITS ❑ Depth Size Number Ni SUMPS ❑ Distance to nearest: Well Foundation Property Line 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. j 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." ni. The applicant must call for all required inspections. Complete drawing on reverse side. Signed X �Uaurp Title: e Date: �1 , .t FOR DEPARTMENT USE ONLY ^ Application Accepted by r Date Area y qMq v� Pit or Grout Inspection by Date Final Inspection by - Date �I, .- Additional Comments: A0 . 6 Stk 46C M1 ❑ todi 369-366 ❑ Manteca 7104 ❑ TrAdi!W63165 _ Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO AMOUNT DUE AMOUNT REMITTED - IK It RECEIVED BY DATE / PERMIT"NO. + EH 1324IREV.tiasl EH 144`6