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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA 1 Ob 10 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. oe Job Address _�� 6 Q6V 2. City Lot Size�,O PM Owner's Name 13 1"I_ 113 GC.i T�t7l,D Address __ SAME Phone Zea J Contractor SS Address PQ irJ�C�7 8 License No-_9-n I R-S Phone TYPE OF WELL/PUMP: NEW WELLX WEL=.E&L'ACEMENT DESTRUCTION PUMP INSTALLATION SYSTEM_REPAIR LlOTHER 71 "' DISTANCE TO NEAREST: SEPTIC TANK 10 Q \ SEWER LINES DISPOSAL FLD. PROP. LINE La 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 s 'jL�'Domestic/Private `Z Gravel Pack ❑ Tracy Type of Casing gk C Specifications Fl Public ❑ Other ❑ Delta Depth of Grout Seal oto& Type of Grout_Ctt AA-f _ I I Irrigation —.Approx. Depth X Eastern Srface Seal Installed by _ _r.Ae7lC.9(rJ+� _ Repair Work Done LlType of Pump 5�+�'{ H.P. 1 State Work Done Well Destruction ❑ Well Diameter ' rr Sealing Material (top 501 CtJ+J1�iVr d Depth-,— 114 D Filler Material (Below 50'1 _ TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I ) DESTRUCTION I 1 (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 Ca Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size C FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Cl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 Di1trict. 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." 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." The applicant must call for all required inspections. Complete drawing on reverse side. f Signed X Title: rte(. . Date: I DEPARTMENT USE ONLY Application Accepted by _60,,..A Ifs! _t _ g nnn_ Date Area r Pit or Grout Inspection by DatecYV p l Final Inspection by �/L37+'r Date o�-�D�q Additional Comments: 1 r ❑ Stk 466.6781 ❑ Lodf 369-3621 t7 Manteca 823-7104 0 Tracy 835-6385 Applicant - Return all copies to: Environmental Health hermit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE j INFO OUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE P RMIT'NO. y 1 +.EH13-24(REV.IiHFI) eo v f0� L [ r �p EH 14-25 1�f f ` I