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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT M 1601 E. HAZEL i 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.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. a- - Cit,/–V Job Addre Lot Size PM Owner's XrAlnp in ZdolfAddress Pho ��"� L P T Cont v ddressA1y60.*3-��icense Noy Phone 702 vv I TYPE OF WELL/PUMP: ' I NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ £ SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK - SEWER LINES DISPOSAL FLD. PROP. LINE j FOUNDATION I AGRICULTURE WELL OTHER WELL PITS/SUMPS I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS +� ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing tic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications i ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation _..,--Approx. 9th= ElEastern d rface ea stalled by Repair Work Dane A Type of PumH.P. State Work Dan ar Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ lNo 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 Distance to nearest: Well Fou6dation Property Line LEACHING LINE ❑ No, & Length of lines i Total length/size FILTER BED ❑ Distance to nearest: Well Fodndation Property Line } SEEPAGE PITS LJ Depth Size f Number SUMPS ❑ Distance to nearest: Well . Foundation Property Line DISPOSAL PONDS ❑ I y 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 certifiesthe fo Ing: "l certify that in the perform ce of t work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of ali rnia." The app" t t call for r quired ins ctio . Co to drawing o e side. Signed Title:w Dat r FOR DEPARTMENT USE ONLY Application Accepted by Dat Area Pit or Grout Inspection try Date Final Inspection by Dat ! a Additional Comments: n ❑ Stk 466-6781 cdi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8354= Applicant- Return all copies to. Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEEI i INFO AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT`NO. �p + E413-24(REV.1/951 EH W28 / 7