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APPLICATION FOR PERMIT SAN JOAdUIN LOCAL HEALTH'. EALTH DISTRICT 1601 E. HAZEI_TON 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. Job Address r I' c7 � City 1. JA A Lat Size 3 `,4 PM Owner's Name Address 1/J U %tJ Phone Contractor's Name In gE� License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION It 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 PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing F`-+ ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done "0 Type of Pump H.P. State Work Done Well Destruction El -Well of Sealing Material {top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATIO I REPAIR/ADDITION ❑ DESTRUCTION ❑ Wo septic system permitted if public sewer is „. kms. rte.... w.� �. ,.�x. a �.,” 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 L Capacity I J No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal F1. Distance to nearest: Well�� Foundation Property Line LEACHING LINE fA No. & Length of lines Total length/size (� C'n Q FILTER BED © Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ 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 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."Contractor's.hiring or sub_aontracting_signature_— �' certifies"the folldWng:"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 1t rail for all requir d ' ctlops. Complete drawing on reverse side. C f Signed Title: ! D �� Pt` Date: T i FOR DEPARTMENT USE ONLY Ap I' t' Accepted by ,�• T 'i i r`_ Date _ Area rkt� Z: 1?it-orBrot Inspection by hJf ��p iQ/lf��— Date ,� 7 Final Inspection byWDate, Additional Comments: 1,�`r_"►3�0 �• 0- —3-1—QGf ❑ Stk 466-6781 ❑ o —363ki ❑ Manteca 823-7104 ❑ Tracy 835-M Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT"NO. O + EH 13-24 iREv.1D/831 '.j "Ll�, o 1 a -7 f P g Li-1 Li°4a EH 1428