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Il i S II APPLICATION FOR PERMIT y SAN JOAQUIN LOCAL HEALTH DISTRICT I! 1601 E. HAZE 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. I' Job Address � F 1't/ � 1 .C�<T`/ ' .�: � � �� / City M1'�/�G.� Lof ize" X �� PM Owner's Name l�Y 1�'I, �G7 f it l� e +� r Addres ��• Z : .`� hone G Contractor e9I Address !f License No�j''-' Phone TYPE OF WELL/PUMP: !� NEW WELL ❑" WELL REPLACEMENT'❑ DESTAUCTtON ❑ r PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER"p A' DISTANCE TO NEAREST: SEPTIC TANK ' SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION t AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED^USE—"TYPE'OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industria1%...",,._4_ El`OFpen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private `d Gra'vel_Pask,� ❑ Tracy Type of Casing Specifications ❑ Public `" 1❑ Other T❑.Delta Depth of Grout Seal Type oii6rou f ` ,C7 Irrigation\,. y o : <-'tApprox. Depth_ .❑ Eastern Surface Seal Installed by Repair' Done `.❑ t .Type of Pump i ``f H.P. State Work Done i 5 •6 Well Destruction' ❑ Well i Diameter Sealing Material (top 501 +' --f-bDepth � �s Filler Material (Below 501 TYPE OF SEPTIC WORK: 'NEW INSTALLATION i❑ REPAIR/ADDITION C1DESTRUCTION (No septic system`permitted if public sewer is available within 200 feet.) {T Installation will serve: Residence 1 Commercial Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: . — Water table depth t, SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal f Distance to nearest: Well Foundation Property Line i LEACHING LINE` ❑ N11871 Length of lines ''T�' rt`�.0 "� Total length/size FILTER BED ❑ Distance to nearest: Well Founddtion Property Line "f SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to-nearest: Well Foundation 'Property"Line DISPOSAL PONDS El II 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 signature certifies t e following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person' such manner as to me-Sol ct to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the follow" g: "!certify,that i e perfo a of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion fawn of Calif rnia.' The applicant us call quired'i(i Complete drawing on reverse side. Signed Title: Dater t FOR DEPARTMENT USE ONLY r Application Accepted by Date Area /.�7 / Pit or Grout Inspection by Date Final Inspection b Date / I l Additional Comments: f ❑ Stk 466-6781 ❑ Lo .il 369-3621 ❑ Manteca 823-7164 ❑ Tracy 835-'685 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA"95201 e rf?v �^ pv/ INFO FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY GATE PERMIT N0. n i + EH 13-24(REV.t)e 51 '� EN 14-28' b f rl