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APPLICATION FOR PERMIT 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 I District.^ r Job Address e.?^7 '^� ►/�1 I I 1 1 , �� (y q City t �ott Size PM Owner's Name 1{:�.I{„k.v-v� 2—�� Address �� r _ �1i✓_CX�� Phone —T t• Contractor 111,311 .2 f— Address a36 Al License No.40 / Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ` PUMP INSTALLATION ❑ SYSTEM REPAI 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 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing S±E?L Specifications Public ❑ Other ❑ Delta Depth of Grout Seat Type of Grout I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump � H.P. \: - State Work Well Destruction ❑ Well Diameter r Sealing Material (top 50'I z1 Depth_�.,S.Z Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION I I DESTRUCTION I I (No septic y�Mr-In.11 r RM it public sewer is 'table�aAf9et.�1 .P A Installation will serve: Residence_ Commercial_ Other MP1ROnl,��r r r(�t^1 II "�� oo` Number of living units: _ Number of bedrooms 7'�"pV�T-AL LICA N Character of soil to a depth of 3 feet: Water tra5le#eRv eis f-I�q�Tf �. SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments b PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line .[ LEACHING LINE ❑ No. & Length of lines Total length/size D FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number t. 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 pe so n uch manner as to become subject to workman's compensation laws of California.”Contractor's hiring or sub-contracting signature certifies the follo rn . "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. ' r The applic t call for all reqs. s. Complete drawing on r �vlIp�rse side.fl — Signed X Title: -�'n(P 1/t't 1hf.1_' C� Date: FOR DEPARTMENT USE ONLY �. Application Accepted by Date Area ,2�J ZZ Pit or Grout Inspection by Date Final Inspection byan �T_ Dat r Additional Comments: ❑ Stk 466-6781 ❑ L i 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.P. Box 2009, Stk., CA 95201 INFO AMOUNT SD)UE AMOUNT REMITTED CASH RECEIVED BY DATE PiEflMf1-7 v'�NO. SEH IX24 IREy.1/N51 Jliar✓ I��p�� 1 ®Vv� EH