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APPLICATION FOR PERMIT k SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ; Y : (Complete in Triplicate) I 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.,,-_ w r Job Address k 1,1 City �`--� Lot Size �/TG pry1Name f. a� !� U E')r�rPhone Address` 0 g.Contractor.'s Name' `"-.,.�: " `" F'- �� --•� 4�-.-License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ N DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _DISPOSAL FLD. -pROp, LINE d FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS V 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 f Type of Gasing s < � ❑ Public "` - t Specifications ❑ Other; ❑ Delta Depth of-Grout-Seal �� Type of Grout � ❑ Irrigation ---Approx. Depth ❑ Eastern Surface-Seal Installed by '` A; Repair Work Done ❑ Type of Pump1 H.P. F. ' State Work Done— --- ._- 1-4Well Destruction ❑ Well Diameter 1 'Sealing Material Itop SO')-' Depth ' Filler Material (Below,50') -_ - TYPE OF SEPTIC WORK: NEW INSTALLATION E REPAIR/ADDITION"❑- DESTRUCTION ❑ (No septic system permitted if public sewer is t *� available within 200 feet.) Installation will serve: Residence vCommercial Other pp Number of living units: Number,of bedrooms Character of soil to a depth of 3 feet: I Water table depth n SEPTIC TANK / Type/Mfg /CP �?�Cpacit�y ' ~ 'f/ — C) No. Compartments . PKG. TREATMENT PL ❑ "�' � � _ G ``/��„ { f Method of Disposal ' Distance to nearest: Well oundation l+] - i � Property Line LEACHING LINE No. 8i Length of lines 'd ` jTotal length/sizelo FILTER BED ❑ Distance to nearest: Well oundation^ �U �* Property,Lin " eR SEEPAGE PITS Depth A0 SizeNumber ZOe SUMPS "❑ Distance to nearest: Wei r ,G. Foundation_1 = propersq Line'�0 .i DISPOSAL PONDS El � 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. f T 1 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 subjecf_fo-workman's compensafi&i laves of California."Contractor's hiring or sub-cbntracting signature certifies the following: "I certify that in the performance`of-the`work for which this permit is issued, I shall employ t tion laws of California." - P Y Persons subject to workman's compensa- The applicant must call fo all requi inspections.. orhplete drawing on reverse side. f , Signed Title: # * Date: » _ y., A, kr _ FOR DEP RTMENT USE ONLY } Application Accepted by _ € D eArea O —C Pit or Grout Inspection by t to Final Inspection—by C) y Date Additional Comments: -C< ., ,✓-.�.. T�' ��" - �, ❑ Stk 466 6781 Manteca '(823-7104 ❑ Tracy 835 638.5 ' Applicant- Return all copies to: Environmental ealth Permit/,Services 1601 E. Haielton Ave., P.O. Bax-`2M"9 .Stk.; CA 95201 F» .�. ' . 'Sr— AM FEE AMOUNT-DUE-_ --AMOUNT REMITTED INFO _c f RECEIVED BYE' DATE PERMIT'NO. + EH 1324 IREV. 10/931 _ EH 1429 CA