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f f --" APPLICATION FOR PERMIT (ay. }yr.c14 r 4v Ce-t,hc SAN JOAOUIN LOCAL HEALTH DISTRICT -� `r -�4.fkV I'.- ' Cyte 1601 E..HAZEL T ON AVE., STOCKTON, CA a h fl-er .; I Telephone (209) 466-6781 PERMIT EXPIRES 1YEAR 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. A f 7 'A Job Address ( I� ° City Lot Size 9,5 F/� PM Owner's Name Address f• L^�0 PhoneIle ''ffVis'- '9 I Contractor! -'Address ,944, �^=License No. Phone'. TYPE OF WELL/PUMP; 11 NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ s PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 3 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-� -� 11 Domestic/Private ❑ Gravel Pack 11 Tracy Type of Casing - Spec'if'ications ' ❑ Public ❑(Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation '—Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done' r Well Destruction ❑ Well Diameter ; Sealing Material (too 501 1 I Depth Filler Material (Below 601 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/A ITIO DESTRUCTIO ❑ {No septic system permitted if public sewer is .j ailable within 200 feet.) Installation will serve: Residence_ Commercial_ Other n/ � �� + Number of living units: Number of bedrooms -- - / �/� +"711/ Character of soil to a depth of 3 feet: Water}table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. L7 Method of Disposal f Distance to nearest: Well Foundation Property Line 6�. /LEACHING LINE' ❑ No� &Length of'lines cry t Total length/size FILTER BED ❑ '! Distance'to.nearest: Well oundation Property Line - 1 SEEPAGE PITS' - ❑ 1 Depth Size J. Number € SUMPS f.�, ❑ II Distance to nearest: Well Foundation Property Line DISPOSAL'PONDS ❑ - <a-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. I "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 -wer plroy 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 applicapt must call r,all req fired inspections. Complet drawing on reverse side. r Signed Title: rn.��- Date: F �i FOR DEPARTMENT USE ONLY 71 Application Accepted by Data 2 Area V Pit o►Grout Inspection Date Final Inspection b Date ��2. Additional Comments: � El Stk 466-6781--='Ll-l:bdi-369-3621."-❑ Manteca._82;i=7104❑1racY Applicant- Return all copies'to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO CASH + EH 13-241REV.1/e 51 �1�.� �� —'/ EH 14-26 - al.