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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephorte (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is herebymade to the S 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�" Tr(✓ -r-� City - lot Size PM Phone Owner's Name /!��i�?J"1CJ �C�/L/�.�-Address fa��/ �L-`,�'�'^'� Contractor AddressLicense No.sl -�� Phone TYPE OF WELL/PUMP: N WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 0 DISTANCEITO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE F r �`< FOUNDATION AGRICULTURE WELL. OTHER WELL PITS/SUMPS k IINTEN4ED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS _ C] Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private C] Gravel Pack 0 Tracy Type of Casing Specifications I l Public 1-1 Other n Delta Depth of Grout Seal .k {Type of Grout __ I I Irrigation --Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done 0 Type of Pump _ H.P. State Work Done_ Well Destruction /ISO iameter Sealing Material Ito WZ TYPE OF SEPTIC ORK: NEW INSTALLATION 11 REPAIR/ADDITION 1 1 DESTRUCTION I 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 TANK '❑ Type/Mfg Capacity No. Compartments G PKG. TREATMENT PLT. 0 Method of Disposal 1 Distance to nearest: Well Foundation. Property Line LEACHING LINE 0 No. & Length of lines Total length/size i �I FILTER BED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS 1 1 Depth Size _ Number t SUMPS L7 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 District. Home owner or'licerLsed agent's signature certifies the following: "I cdrtify,that in the performance of the work for which this permit is issued, I shall not employ ipy person in such manner as to become iu'6ject to w-or c}'man's compensation laws`of Caifomia."Contractor's hiring or sub-contracting signature certifies the following: '9 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 quired i omplete drawing on reverse side. Signed X Ile: Date: - FOR DEPARTMENT USE ONLY k � 1 1 Application Accepted by Date dam^ Area l Pit or Grout Inspection b Date Final Inspection by Additional Comments: &\11 ".a slo Y� 5t.� cJ /C o �� /t/�Ii` ❑ Stk 466-6781 ❑ 1 O Ma eca 3-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2005, Stk., CA 95201 1FEEO AMOUNT DUE AMOUNT REMITTED CASK RECEIVED BY -DATE PERMIT'NO. +.EH13-241REV.tix57 /7 q-17_47 EH 11-28 ✓✓✓ ( 111