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r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED IE (Complefe 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 <� C �� /'xi� City Lot Size /Q^___ PM ! Owner's Name Address _ ) Phone ro Contractor dydAddress License No. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C7 DESTRUCTION ❑ -PUMP-INSTAL-L-ATION..©_.,__-._.- -,-,.,SYSTEM.K PAIR q___ OTHER ❑ j DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. ROP..LINE i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE ITYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia': of Well Casing �r ❑ Domestic/Private O Gravel Pack ❑ Tracy Type of Casiing� Specifications f`I Public C'l Other ❑ Delta Depth ofIG/rout/Seal Type of Grout I } Irrigation Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. t` State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 50) \r, DepthMaterial-{.Below 50'1 TYPE OF SEPTIC WORK: JNEW INSTALLATION,!1 REPAIR/ADDITION (&J DESTRUCTION I I (No septic system permitted if public sewer is n aveajlablleywi in 200 feet.) Installation will serve:. Residence_ Commercial_ Other�Cg7Q•t1C]re�! ["e-C Number of living units: Number of bedr ms ( � J Character of soil to a depth of 3 feet. �,,, /�^�------. Water table depth (06 t SEPTIC TANK ❑; Type/Mfg _ Capacity Na. Compartments PKG. TREATMENT PLT. ❑? j �� Method of Disposal Distance to nearest: Well Foundation c Property Line LEACHING LINE i No. & Len Length of lines t 9 9 Total length/size 446 l' t FILTER BED ❑ Distance to nearest: 4+Weii �4' Foundation _ Property Line � _ t SEEPAGE PITS C1 Depth 's Size W ° ( _ Number ' SUMPS Distance to nearest:o� Well 4-_ Foundation_ Property Line ' 3,� DISPOSAL PONDS ❑; ty� j }] r I hereby certify that I have prepared this application land that li' V'ork will be done in accordance with San Joaquin co6ty ordinances, state laws, and M rules and regulations of the)San Joaquin Local Health District. -! ' I Homeowner 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 signature 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." M Thea lican[must call for I! 1 Fpp I quired inspections. Compete drawing on'reverse si e. lJj � ( - Signed X `J - Title: 4W A)Gk pate; r FOR DEPARTMENT USE ONLY r Applica ' n Accepted by Date I Area z tion by D Final Inspection by Additional Comments: 1 ❑ Stk 466-6781 - ❑-L-odi-•-3fi9=3821 EI-Manteca--@23--104 ----8-T-racy--835=6385 Applicant - Return all copies to: Environmental Health Permit/Services'1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT �DUE AMOUNT REMITTED CASH 4 RECEIVED BY DATE PgEER�MITT*N0. a.EH 3-24)REV E 4-2e 20 , 66 7o..,Ll� 126;, Z-4011,2 Xr� H 11