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APPLICATION FOR PERMIT " *" SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA 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.TMs 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. 11 i Job Address h 1'\ Q CityS C Lot Size ct G G PM Owner's Name—�OP%-� � J � 1 e iM m)e, ress _1_0 Jf� 2 nZ 21�% Phone w� Contractor's Name _LZ r w License No. ''t - Y Phone ' O� TYPE OF WELL/PUMP:. NEW WETt Kr WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION K SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANKy-7-00 SEWER LINES DISPOSAL FLD. PROP. LINEe:2-4-0y FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS,5j' o E INTENDED USE P OF-WELL WELL PRO�� BLEM AR _.--�^ �� . EA CONSTRUCTION SPECIFICATIONS � l El Industrial Oen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing V°Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications e ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout 9 ❑ Irrigation 1 —Approx. Depth ❑ Eastern urface Seal Installed by k Repair Work Done ❑ Type of Pump SO b • H.P. State Work Done Well Destruction ❑ t= Well Diameter Sealing Material Itop 501 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.) Q� Installation will satire: Residence_ Commercial_ Other Number of living units:;'*- Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK 0. k7 Type/Mfg YP 9 - ._.._ Capacity No..Compartments_. IPKO TREATMENT PLT. ❑a" *. 6 Method of Disposal Distanca`to nearest: Well Foundation Property Line i l LEACHING LINE ❑ No. & Length"of lines t Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line I' f SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: N 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."Contractor's hiring or sub-contracting signature 4 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." c ► The applicant must call for all required inspections. Complete drawing on reverse side. 3 Signed rnU�` Title: -5 r _ Date: o FOR DEPARTMENT USE ONLY Application Acceptedy Date 1g-2 c. Area / f Pit or Grout Inspection Date Iib Final Inspection b Date ' Additional Comments. 11 Stk 466-6781. ElLodi 3694621 ❑ Manteca 823-7104 ElTracy 835-6385 a Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE'+ ` fj,41VIOUNT REMITTED CK# RECEIVED BY DATE PERMIT"NO. INFO CASH r- + FH 13-24(REV.10,83) �J�] fir, 11f-.7 a v �',- 1 V 6 n-.JS EH 1426 S.,. - -- - ___.�