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APPLICATION FOR PERMIT IU .PNA SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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./e /' Job Address Z MOD C. • (o I,4e Y-- e City' /0� Lot Size �1"t PM u 9Y5- Owner's Name 04ye Marcetf1 Address Z7 �S P�04LI"� 7'�"t^�t'�)O Phone 5-3-1 - -1 J 1 . Contractor Address 9—LEd 9091 a K - License No. 36h--S SI Phone �1 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE Za FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS S/ Ll Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing / I)II,Domestic/Private Gravel Pack ❑ Tracy Type of Casing � PSpecifications J� I'I Public ❑/Other Ll Delta Depth of Grout Seal ,cs,1� Type of Grout_&V-AL� L�_ I I Irrigation 3W Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump S(41AJ H.P. 7— State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1 I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) d 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 y/1 LEACHING LINE Ll No. & Length of lines Total length/size !� FILTER BED C] Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number r SUMPS I I Distance to nearest: Well Foundation to line DISPOSAL PONDS [I 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 D3trict. 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." Contractors hiring or sub-contracting signature canities 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 Californi ' The appli::Z4 ant u (ncall for all requir ' spection�.omplettee drawi on reverse side. 9�l Signed X �l .L,A 7 4Z!'�-f-�n/'� : ✓ . Date: 1 L FOR DEPARTMENT USE ONLY G{ Application Accepted by - Date \ Area d. Pit or �V rout I spection by �a, Date��Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lgdi -3621 ❑ Manteca 1123-7404 ❑ Tracy 835-6385 Applicant- Return all copie to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2(109, Stk., CA 95201 5 AMOUNT DUE AMOUNT REMITTEDTCCASH RECEIVED BY DATE PERMIT NO. . EH 324(REV.vx ,f ,��JJ EH I4-24 INFO il •v Qta ��