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APPLICATION FOR PERMIT D SAN JOAQUIN LOCAL HEALTH DISTRICT V 1601 E. HAZEL T ON AVE., STOCKTON, CA AUG 2 8198? Telephone (209)466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIROMENTAL. HEALTH (Complete in Triplicate) Applicatiot�ii k�i �e�tYolthe�SSan 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 t+ 46 6AJ 9 City/10C-/&7e15_` Lot Size PM Owner's Name F7 �j "r7su,�a N Address ��3'�/� Phone �" 1316 UNfVL;r-A,,q L I �1 / Contractor U P" /' L Address�6 /� /2d License No46'<741 Phone TYPE OF WELL/PUMP:_ NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 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 r Domestic/Private .❑ Gravel Pack ❑ Tracy Type of Casing Specifications 17 Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout Q I I Irrigation _..Approxi Depth i I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. Z-7-- State Work Donef pu,,r,:(L! ! Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth 1 Filler Material (Below 501 n TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION 1_1 DESTRUCTION i I (No septic system permitted if public sewer is I 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 Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE .❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I Depth I Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑_.. –y ..:..�.�..R� _ .: �:- .� ,.�:�: .�.��• -,.�. 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 ' nature 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 ma er s to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature ; certifies the following: "I cert in the 9evormance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." i The applicant must call f r.qu- ins ct omplete drawing on reverse side. Signed X Title: n 11 AJ r*_ – Date:/ _ FO t]EPARTMENT USE ONLY Application Accepted by Date Area /L✓ j 2 Pit or Grout Inspection � Date Final Inspection b Date✓ Additional Comments- 0 Stk 466-6781 ❑ Loi 369- Manteca 3-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E.'Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. + EH 13-24(REV.t i e s1 0 O r �� 4 ot EH 14-26 :