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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 1209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 4 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. ift k II Ie Job Address � (:,q I I< im City /�ot Size PM Owner's Name r� It ,kyp 1' 12c Address V22�19 aw 7Cckd Phone V. Contractor Address License No.��Phone TYPE OF WELL/PUMP: EW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Ilia PUMP INSTALLATION ❑ SYSTEM REPAIF 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 Dia. of Well Casing XDomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing EYI— Specifications 1-1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout_ I I Irrigation Approx. Depth f i I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump —� H.P. \� State Work#Fqne� Well Destruction ❑ Well Diameter _-dSealing Material (top 501 's' ,z Depth ---- Filler Material (Below 501 - lft s TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION t I DESTRUCTION I I (No septic em%itied it ublic sewer is ra Ulabe2 2OW t.,,�� p r Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms R TC�fc`?�T/-� Lj A T Character of soil to a depth of 3 feet: Water t I5I&`3aA '' is / 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 11 Depth Size Number SUMPS D 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 Di3trict. 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 pars. m uch manner as to become subject to workman's compensation taws of California."Contractor's hiring or sub-contracting signature certifies the toll. in . "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 ia." rr The applic t call for all req i ed Apons. Complete drawing on r v rse side.Q Signed - Title: � F ( tTh'h_1Q� Date: FOR DEPARTMENT USE ONLY Application Accepted 6y Date-a=� Area Pit or Grout Inspection by Date Final Inspection by 1��T Dat t. 'n }' Additional Comments: U1(L r d' ❑ Stk 466-6781 ❑ L i 369-3621mean..❑-Mantec4 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.P. Box 2009, Stk., CA 95201 ^ NFO AMOUN/TSD�UE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. a�l' i EH 1324 1REV.r/x 51 �fi�✓ I,�l yx � ' �' EH 1 (V