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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA S/ Telephone {2091 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.., _5- yrs/ 3 .� Job Address f[ 7 q0 2�G�tK F_o6cf City Lot Size 3-3 X �6•1 7 PM Owner's Name ' l_o LL[2�tr� �T Address �� ILA3 ' (�_ Phone Contractor Address 17 3 ? 16, 64kLicense No.7-A ) 5 72 Phone 334%--1130 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION E] SYSTEM REPAIR ❑ OTHER ❑ 1 DISTANCE TO NEAREST: SEPTIC TANK I00-4- SEWER LINES DISPOSAL FLD.424n PROP. LINE s5V FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPSa x INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �S ❑ Industrial Wpen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing /�omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 10 AIN I f'1 =Public ❑ Other ❑ Delta Depth of Grout Seal1 Type of Grout I 1 Irrigation q ,_,__-Approx. Depth. 1,1 Eastern Surface Seal installed by Repair Work Done ❑ Type of Pump H,P. State Work bone Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 \V TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION l I (No 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: ater table depth SEPTIC TANK © Type/Mfg 1 y. No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal 4�� l Distance to nearest:>- Foundation "' Property Line LEACHING LINE ❑ No. & Lent lines '� r c� g Total length/size FILTER BED ❑ Distan o nearest: Well Foundation Property Line SEEPAGE PITSe l Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL POND,%/, _ I.hereby certify t4af I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regularons of the San Joaquin Local Health District. Home owner or licensed ' a ents signature certifies the following: I g g g: "I certify that in the performance of the work for which this permit is issued, I shalt 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." The applicant iu t call fo I-required in pections. Complete drawing on rev rse side. a ! .. Signed Title: Date 4 FOR DEPARTMENT USE ONLY FF Application Accepted by Date 0___—7116 Area Pit or Grout Inspection by IN ate Final Inspection by t R Date Additional Comments: Zf ❑ Stk 466-6781 ❑ Lo 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 1 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMiT'NO. _ INFO.. - t� CASH J ..EH 13-24 IHEV,1/H s] J� .. C'A EH 14-26