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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6761 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 M made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1882 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. -Inh Addreec rJ `cV L • 8 Mize— /2ct 111v 51A1+04i%Iq I nr Si,. ou Owner's Name T &/�1� L?/OwJL15 Address Siiv1.G Phone ,3V DUE Fir...,.r 4ys� Contractor /�.fc.��-s(Crii Address License No. i9VV `/r Phon�y�s TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHEf�F!'LK Swr/ Z --"A7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE c9�1,41 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI NS Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal M Type of Groutb. ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK:. NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is 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 ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line 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, and rules and regulations of the San Joaquin Local Health District. 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 employ any person in such manner as to become subject to workman's compensation laws of California." Contractors hiring or subcontracting signature certifies the following: '9 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 muJsj�call�tor all required inspections. Complete drawing on reverse /side. / Signed X_ Title: Title: ^ rSCCari'13� Date: Application Accepted Pit or Grout Date Area Additional Comments: �' ' - ❑ Stk 466-6781 ❑ Lodi 369 -WI Cl Manteca 923-7104 ❑Tracy Applicant - Return all copies to: Environmental Heaith Permit/Services 10D1 E. Hamilton Ave., P.O. Box 2009, Stk., CA 95201 EH 13-74 IREY. I / e sl EH 1470 FEE INFO INFO DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. 3s 03 c9�1,41 u'is7 71g7