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E APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 9 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. Job Address Zz J 3 E kom City Slkkh A.) Lot Size PM Owner's Name 1111"-mer Address Sipa Phone 9� / Contracto t ilo, Address icense No. Z24f2A Phone o `72z'7 ?f TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ "—PUMP INSTALLATION ❑ ? SYSTEM REPAIR ❑ OTHER O 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 0 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing -Specifications 1-1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Gr"out _ I f Irrigation __-Approx. Depth l I Eastern Surface Seal Installed by _ Repair Work Done U Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter I Sealing Material (top 501 Depth I Filler Material (Below 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION DESTRUCTION I I (No septic system permitted if public sewer is 1 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: ' v Water table depth SEPTIC TANK I] Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ r Method of Disposal M "Distance to nearest. Well Foundation Property Line LEACHING LINE No. kLength of lines �' `.h♦ __.__ Total length/size FILTER BED ❑ Distance to nearest: Well Foundation f0'' Property Line_.1A Y I' SEEPAGE PITS �, i� TT }C� Depth Size �_ _ Number SUMPS I] Distance to nearest: Well ,_ Foundation jn/ Property Line /d DISPOSAL PONDS ❑ 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, ar� rules and regulations of the San Joaquin Local-Health District, Horne 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 signatur 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 must call for all required inspections. Complete drawing on reverse side. Signed X— I.ti�, r +" — Title: Date: — S 0 O EPARTMENT USE ONLY ' Application Accepted by Date Area Pit or Grout Inspection by a ' Date Final Inspection by Date Z Q Additional Comments: lfk f / ❑ Silk 466-6781 L]trodi 369-362-1. � rL// SS �,grsp ❑ 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 I INF EEE AMOUNT DUE AMOUNT REMITTED K H RECEIVED BY DATE PERMIT'NO. z + EH 13-24(REV.I/H 57 f SCJ/ •� Lgo O /.:ZQ4EH 14-26 �► a f ' 4