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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 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.r-y /j f Job Address J /l6 7 1 J ! e 11 ?CQ Cid, ,Sc � Lot Size 50cr PM �U �/ [ Owner's Nam / !hl1� Address SAMA97 Phone Contractor's Name l�n s �o.� License No. 83C� - Phone -r — !q TYPE OF WELL/PUMP: /'.NEW-WE616 O-- WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ f 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 PROBLEMAREA. CONSTRUCTION SPECIFICATIONS C industrial "k .❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing _0 Domestic/Private ❑ Gravel Pack ❑ Tracy - Type of Casing Specifications , ❑ Public ❑ Other ❑ Delta of Grout Seal __,.Depth Type of Grout ❑. Irrigation --LApprox "Depth ❑ Eastern _- Surface Seal Installed by Repair Work Done ❑`� Type of Pump{ H.-P. IState Work Done Well Destruction ❑w Well Diameter ^Sealing Material (top 501 ' Depth "_ Filler Material IBelow 501 _t` TYPE OF SEPTIC WORK: NEW INSTALLATIpNX REPAIR7ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residenc4_!�&"'Gommercial- Other r a .Number of living units: 'Numb72E&9n7ap Character of soil to a depth of 3 feet: Water table depth f� SEPTIC TANK Type/Mfg acity l 90+7 No. Compartments !' PKG. TREATMENT PLT. ❑ _ ; _ �' Method of Dil!l1osPI Distance to nearest: WellFoundation�� Property Line sLt t� LEACHING LINE No.•.& Length of lines i Tgtal length/size FILTER BED A Distance to nearest: Well ('Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS At distance to nearest: Well �-` Foundation _ Property Line 1 DISPOSAL-PONDS ❑ 1 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:' 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.' f J. The applicant must I all requi d ins tions. Complete drawing on reverse s'de. -.k h Signed • V Title: Dater FOR D PARTMENT USE ONLY { Application Accepted by - y Date Area Pit or Grout Inspection by Date Final Inspection by Additional Comments: _ C1 Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835=6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton:Ave: P.Q."Box 2009, Stk., CA 95201 I1 FEE AMOUNT DUE AMOUNT REMITTED CK 4 „�'' INFO CASH RECEIVED BY DATE x POWIT'NO.' + EH W241REV.10!631 EH 1426` c� - C• r g•b �`� x