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APPLICATION FOR-PERMIT �4- SAN JOAQUIN$LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 12091 466-6781 Syi:, � � PERMIT EXPIRES'I.YEAR FRbM DATE iS$U D,.rY _ J.j �� (Complete,in;Tfiplicatel:, Yt'w.!. ".. 'moi L� '.: fst, E.fi .,a OC)fe Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work h$rein descriBed This application is made;in.compliance with San Joagwn County Ordinance No_549 for.sewage or?Noi,1862 for well/pump and the Rulleeslan�d Regulations of the San Joaquin Local Health District.F I }t" .# i ^r 'r - ?d1 5=' rlu € off cs ,I Job Address City Lot Size PM ate_ .._-_ _._ - yG;�i Owner's Name +��_._ Addressl . ..�'-._. .. _..:-.:Pho�+�: 310, Contractor's Name License No. +� __ Phone TYPE OF WELL/PUMP: 1NEW WELL!❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ' r PUMP INSTALL ATION: `SYSTEM,'REPAIR ® OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL :OTHER WELL PITS/SUMPS , INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS c Q Industrial ' ❑ Open Bottom ❑ Manteca pia. of Well Excavation Dia. of Well Casing t ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type-of Casing Specifications ,❑ Public ❑ Other El Delta Depth of Grout Seal r Type,of Grout ❑ Irrigation —L4pprox..Depth ❑ Eastern Surface Seal Installed by > �._. /1 R ® Repair Work Done 1 Type of Pump t +' H.P. � : State Work Done Well Destruction El Well Diameter Sealing Material (top 501 i �- Depth Filler Mateirial (Below 501 TYPE OF SEPTIC WORK_: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer isp t available within 200 feet.) . ZZ l' Installation will serve: Residence_ Commercial 6 Other V -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 C3i I Method of Disposal 'Distance to nearest:' Well " Foundation Property Line { l 'LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED' ❑ Distance to nearest: Well Foundation o- i Property Line SEEPAGE PITS ❑ 'Depth ; SizeNumber .SUMPS"-,- ❑ 'Distance to nearest:'. WellFoundation Property tine 4•, DISPOSAL PONDS '❑ hereby certify,that I harie 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 Joaquiri Local Health District.- Home istrict.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' j certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall employ persons subjecttoworkman's compensa- ; tion laws of California." The applicant must call r all'required inspections Complete drawing on reverse side ; : Signed Title: I i FOR DEPAr ..__ ;.- _ e a ... _.. . ..... De;� k # RTMENT.USE ONLY l i 'Application Accepted bye Date �14rea 4 i !Pit or Grout Inspection by Date Final Inspection by�/ �4Lj > 4-e� i Date7- Additional Comments: ( i ` ' ..( tk- 466-6781 -- EILodi 369-3621 .13 Manteca' 823-7104- --❑ Tracy 835-6385 _ i _. y.__.r .. i_. b - i sApplicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,,Stk., CA 95201E i _. i. f FEE ` .AMOUNT DUE AMOUNT REMITTED ', ±RECEIVED BY * * ' DATE P.ERMIT`NO INFO CASH I t s + EH 13-24(REV.10/831 EH 14-26