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y, APPLICATION FOR PERMIT } SAN JOAQUIN LOCAL HEALTH DISTRICT �] f 1601 E. HAZEL T ON'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. /� / l- Job Address 1 ,....,,.-.l� l V(! a�Cfrf l City CC Lot Size PM s Owner's Name & e SG Address _ ✓`7'1n e _ Phone / - V a I^ i Q rR�ed leoq�l Qa 4 a0 -t�39 Contractor J Address icense No..�f'I1ane TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION L1PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 190 f SEWER LINES � t'f' DISPOSAL FLD. PROP, LINE �� FOUNDATION 160 AGRICULTURE WELL OTHER WELL !6P INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑Domestic/Private Gravel Pack ❑ Tracy Type of Casing— S42 Specifications "Y t `i-1 Public Cl Othe ❑ Delta Depth of Grout Seal Type ype of Grout j��_. �� - ��pprox. Depth I I Eastern Surface Seal installed by - i Repair Work Done � ❑ r� Type of Pump H.P. A3• State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50`) Depth ? Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION ( I (No septic system permitted it public_sewer is available within 200 feet.I Installation will serve, f Residence: Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: _ Water table depth SEPTIC TANK 6'�"Type/Mfg) _ Capacity • a No. Compartments PKG. TREATMENT PLT. ❑ '�.� ; 'y 1" j' Method of Disposal .� f 11 Distance,to{ nearest: Well Foundation Property Line r 1 LEACHING LINE ❑ No. &'L�gth of nes Total {ength/size FILTER BED ❑ Distance to nearest: Weil Foundation Property Line SEEPAGE PITS f i l Depth p �tze _ Number SUMPS f;� {.i ❑ Distance to nearest:, Weil\ Foundation Property Line DISPOSAL PONDS t ❑ 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, ani rules and regulations of the.San Joaquin:Local Health District. Home owner or licensed agent's signature certifies the.following: 1 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 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 Califor ! ` The applicant m�t call for'el! r' red ins. rytions. Complet drawing`on reverse sde. Sig ned X ^' Title: �� f 7-1) Date: FOR DEPARTMENT USE ONLY �� Application Accepted by Date y Area f Pit o rout nspectionr'by -.✓_`_ _ _Da _ Final-Inspection-by Date 1. CRS ��f/ i f / i �. f ; Additional Comments: Eb6r / .6.--� aQ .• -,-e ❑ Stk 466-6781 odi 369-3621 ❑ Manteca 823-71 �_ ❑ Tracy 835-6385 x Applicant - Return all copies to: Environmental Health`Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTEDICK CAS RECEIVED BY O TE PERMI-r No. v' +.E13-24[REV,I/e y t EH 14-26 V � / � , .