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APPLICATION FOR PERMIT SAN JOAQUIN'LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA f ti Telephone {209} 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED i J (Complete in Triplicate) i 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 4 Local Health District. 1 Job Address r/d�►'j City Y" Lot Size : -,7 41412—r,o PM Owner's Name i/ L✓ v Address Phone t ' Contractoddress '' ' °rh License No �7j7 r < Cc.� P h o n iF?/ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT.r❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ !SYSTEM REPAIR'❑` OTHER ❑ DISTANCE TO NEAREST: SE SEWERTINESl '" ''r DISPOSAL FLD. PROP. LINE FOUNDATION ICULTURE WELL. -OTHER WELL PITSISUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA- C TION SPECIFICATIONS ❑ industrial ❑ Open Bottom ❑ Manteca Dia. of Well'Exca { -Dia. of Well Casing -' O Domestic/Private ❑ Gravel Pack ❑ Tracy - Type of..CasinSpecifications >, M Public E :n Other f fl°Deltas 134th-of-Grout-Seal*-- a of Grout I I Irrigation Approx. Depth l I Eastern Surface Seal Installed by. ` - Repair Work Done ❑ Type of Pump H.P. State Work Done,_ Well Destruction ID Well Diameter Sealing Material ltop 50') ' t Depth Filler Material *low 5011 TYPE OF SEPTIC WORK:-NEW-INSFAL-LATf0N+1 I1 REPAIR-/AUDITIO -h--DESTRUCTION--I-HNo--septic system permitted if public sewer is {� available within 200 feet.) Installation will sere:- Residence'-Commercial Other j Number of living units: __J_ Number of bedrooms -� Character of soil to a depth of 3 feet: ► Water table depth SEPTIC TANKL�ype/Mfg 1 Z_ ___ Capacity JCVo. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No._&_Length of lies Total length/size FILTER BED! ❑v Distance'to nearest: Well Foundation Property Line ;.t SEEPAGE PITS 11 Depth Size Number 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 inaccordancewith 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 followi ertify that in th ormance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of C.I.. rnia.' The applican all t all ire r ctions. Complete drawing on reverse side. Signed X t Title: ��'e�--� Date: hs� FOR DEPARTMENT USE ONLY Application Accepted by Date Area p Pit or Grout Inspection by Y� Date Final Inspection by L Date Additional Comments: "]"Stk"466=6781 ""`--`"❑-Codi' 3'681'""" ❑ anteca 1323-7104 ❑ Tracy-835 6385 ,yy j,/s � Applicant- Return all copies to: Environmental Health Permit/Services 1601 E.-Hazelton Ave., P.O. Box 2 tk-, 52 rr IFEE AMOUNT DUE r AMOUNT REMITTED y CASH .x CK 4 RECEIVED BY DATE PERMIT'NO. NFO L -� I + EH1 3-2401E:V.riesl EM 1429 :j i