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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE 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 Sari 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- l Job Address __ Z G 3 71 Y'l a i ny I na City Es c4,1 o Lot Size PM _ Owner's Name __! _v reC r Address SQnl L _ Phone �� D� Contractor / f Lr 4f K Pu to Address J geed O4d uA*) 4'License No.36"— -S--L Phone_Q i 0- 7 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT Il DESTRUCTION ( ) PUMP INSTALLATION SYSTEM REPAIR Ll OTHER n 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 / I 1 Industrial ❑ Open Bottom Cl Manteca Dia. of Well Excavation Dia. of Well Casing h s/ _ 4k Domestic/Private G�Gravel Pack ❑ Tracy Type of CasingKVSpecifications .��,, Public f Otphip 1-1DeltaDepth of Grout Seal Od1 Type of Grout ��wh I I Irrigation /70Approx. Depth II Eastern Surface Seal Installed by _ Repair Work Done I I Type of Pump _gubol H.P. --I_V 12- State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it 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 Ll Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. [1 Method of Disposal Distance to nearest: Well ___ Foundation Property Line LEACHING LINE 11 No. & Length of lines Total length/size _ FILTER BED L 1 Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth --------Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 11 V I hereby certify that 1 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: "1 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 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 California." The applicant mm s�for all required inspecti ns. Comppllete dr 'ng on reverse side. f� ? Signed X v itle: — j � Date: (r — �pR DEPARTM T USE ONLY Application Accepted by �v�-- Date —�V—� 3 rea_�L__1. Pit or4onspection by Date- Final Inspection b -- Date d i Additional Comments: (I Silk 466-6781 odi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazeltdn Ave., P.O. Box 2009, Stk., CA 95201 ItNFONT DUE AMOUNT REMITTED CK RECEIVED BY ATE PERMIT NO. W Al(v l • EH 13211REV.tinsi 1 i v� r�/) EN t1 IE /�/ 1 TT(� /"�