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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. 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 1 50 (/, - t r ICOM c( - Citv L a i I nt SI7P DM 3 r -3y67 Owner's Name -o.( . Address �-c_ Phon- )33q--3167 Contractor �• k �t� ►1 14 t �*�`�� Address 7-a2"5 C i -1 �� `f'fd h 5 Z ''d / Y4 AW 5 - License No. P h o n TYPE OF WELL/PUMP: NEW WELL'. WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 11 Dia. of Well Casing Z ❑ Domestic/ Private 9 Gravel Pack ❑ Tracy Type of Casing --V C Specifications 11 Public .-.��. El Other ❑ Delta Depth of Grout Seal ( Trp of Grout L-A"et.n El Irrigation P pprox. Depth ❑ Eastern Surface Seal Installed by `� �' -l. �Me\_P C sSv Repair Work Done ❑ Type of Pump H. P. State Work Done Well Destruction ElWell Diameter /. � Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION ❑ DESTRUCTION ❑ (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 PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: 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 certifies the follo'ng: " certify th tlin the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of Calif nia " The applicant mu c r all r ui ed inspections. Complete drawing on reverse side. Signed Title:. a t Date: v C7 r l -_� FOR-OEPARTMENff SE ONLY Application Accepted by Pit or Grout Inspection by Date " / S - S Area l Date Final Inspection by A.11 Additional Comments: ElStk 466-6781 ElLodi 369-3621 1:1Manteca 823-7104 ElTracy 6385 >,.�'G�7itf •P.�Z. , Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O.Box 2009, Stk., CA 99RA1 + EH 13-24 (REV. 1/95 EH 14-26 Date FEE INFO AMOUNT DUE AMOUNT REMITTED, _ RECEIVED BY DATE PERMIT N0.