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APPLICATION FOR PERMIT I SAN JOAQUIN LOCAL HEALTH DISTRICT i. 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 -PERMIT EXPIRES TYEAR 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 we11/pump and the Rules and Regulations of the San Joaquin Local Health District. h� k � Job Address ? City Lot Size PM © ` Phone Q qis 4 ! Owner's Nam I Address (/ Contract�� J Address A9 License No. Z 9-7-Uv PPhone'3G `5I osJ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ r ! PUMP INSTALLATION ❑ 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 ,k r Cl Domestic/Private ❑ Gravel Pack ❑ Tracy k'�, Type'of Casing Specifications l `' Type of Grout I� Other f 1 Delta Depth of Grout Seal Yp I`l Public Other--,-... x_. .— - -� .__._-,:._,..�..,. - — -- - I 1 Irrigation _.Appfox. Depth l.I Eastern Surface Seal Installed by � ' - Repair Work Done ❑ Type of Pump H,P. State Work Done'_ Well Destruction ❑ Well DiameterSealing Material (top 50') Depth ler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION l REPA19>DOITIONK DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence! Commercial_ Other-' f r� Number of living units: __/_ Number of edrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK , Type/Mfg Capacity�f_ No. Compartments q v PKG. TREATMENT PL ❑ r t Method of Diposal Distance to nearest: Well ',619 Foundation Property,Line LEACHING LINE No. & Length of r Total length/size-4076 1( r. 1 FILTER BED 11 Distance to-nearest: Well_�,]�— Foundation._J0 Property Line LS Ill1 SEEPAGE PITS _.-Depiri� :.It�"""""" Size ;% Number SUMPS til Distance to nearest: Well //10 Foundation /d Property Line 147 DISPOSAL PONDS /❑ I,hareby certify that f have prepared this application and that the work will-be done in accordance with San Joaquin county ordinances, state laws, an rules ani) 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 contracting signature certifii§s the following: "(.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 mu all for all judirgo inspections. Complete drawing on reverse'srde tMA.A4- C1 Signed XVaZ �Title: _ 1 Date: FOR DEPARTMENT USE ONLY Date. Area Application Accepted by . ifl� ` J Date l fe P or tout Inspection by Date },"- k ,Final Insp�on b} I Additional Comments: ❑ Stk 466-6761 ■ Locli 369-3621 ❑ Manteca 823.7104 of Tracy 835-6385 1 Applicant- Return all copies to: Environmental Health Permit/Services 1601'E. Hazelton Ave., P.O. Box 2009,�Stk., CA 95201 FEEAMOUNT DUE AMOUNT REMITTED iCASH RECEIVED BY -DATE PERMIT NO. INFO �y +.EH 13.24 1REV.I N 5f Cf,O V ��• � , • �, EH 14-26 1