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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Tri in (Complete liCate) p p (Z.� — 0&0-,71 Application is hereby made to the San J g6in 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. n Job Address n �0�� A Ci —' tY Lot Size PM Owner's Name CA � Address ��. _,�lJl. Phone O' { L. Contractor 1 T 11 1 F�{ : _ Address Er License No.ca Phone61 �1! TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ r DISTANCE TO NEAREST: SEPTIC TANK L)OPE_ SEWER LINES DISPOSAL FLD.KY)QE PRpp_ LIN 1� FOUNDATION t�CaAGRICULTURE WELL OTHER WELL L,)n�- PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 0 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of CasingSpecifications 9 FI Public ❑ Other P(Delta Depth of Grout Seal ^' T i I Irrk ti Type of Grout J9ft�-- � pprox. Depth I I Eastern Surface Seal Installed by 7 \ E Rea or Done ❑ Type of Pump H.P. State WorklDone _ Well Destruction ❑ Well Diameter ' Sealing Material (top 501 E Al — 5 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION I I DESTRUCTION I ] (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 TANKe ❑ Type/Mfg Capacity No, Compartments PKG, TREATMENT PLT. ❑ Method of Disposal + 1 Distance to nearest: Well Foundation Property Line I LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line I SEEPAGE PITS I I Depth ; Size Number ' SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I ,� 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, ander 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, 1 shall note 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 follo ing: "I certify that in the performance of the work for which this permit is issued, I shall employ parsons subject to workman's compensa- tion laws of i ornia." The app' an ust call for all aqui ins ' ns. Complete drawing on reverse side. Signed Title: kAlG TTCA1 k Date: 1� 401;ril;�A�i� EkTEY` \�f y� er t�O Date Area Application Accepted by Z�' 4 9—f Pit or Grout Inspection by f Date Final Inspection by Date Additional Comments: E l-Stk 466-6781 ❑ Lodi 369-3621 1 Cl Manteca 823-7104 C1 Tracy 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 R£MiTTED CASH RECEIVED BY DATE PERMIT N0. <0LJ�— EH 53,21[REV,tin57EH l/2tl +