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APPLICATION FORPERMIT COPY f 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 M"90 ` City d F Lot Size a "' ' - .PM Owner's Name iC% t X19 Cl i " Address """� Phone Contrac r 1t1C t�C�Address L.; �� License Nox ZZ� Phone 10 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES OTHER ❑ DISPOSAL FLD. PROP. LINE FOUNDATION .AGRICULTURE WELL OTHER WELL PiTS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial 15 Open Bottom ❑ Manteca Dia. of W ell Excavation' 12Dgmestic/Private ❑ Gravel Pack El Tracy of.Well Casing Tracy Type of RCasing Specifications Q Public ❑ Other pe � cations ❑ Delta Depth of Grout Seat Type of Grout ❑.Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H p State Work Done Well Destruction ❑ Well Diameter Sealing Material{top 50') Depth Filler Material,IBelow 5011 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ EPA/ /ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is Installation will serve: Residence available within 200 feet.) _ Commercial— Other Number of living units:-__ Number of e rooms Character of soil to a depth of 3 feet: -� SEPTIC TANK{ ❑ T .Water table depth o ype/Mfg Capacity PKG. TREATMENT PLT. ❑ r No. Compartments -„ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of fines Total length/size FILTER BED ❑ -Distance to nearest: Well Foundation Property Line SEEPAGE PITS 2—Depth Size Number SUMPS ❑ Distance to nearest:" Well Foundationf DISPOSAL PONDS ❑ — Property Line_jC�f� +` • I I hereby certify that I have prepared this application and that the work will be dans in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin LocaE 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."Contractors hiring or subcontracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant mu t call for all r quir inspections. Complete drawing on reverse side. Signed Title: Y , Data: c FOR PARTMENT USE ONLY / Application Accepted by Date r - b Area Pit r Grout Inspection b ate �� Final Inspection by Date Additional Comments. ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8354M Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK INFO CASH RECEIVED By DATE PERMIT'NO. 13-241REV.sie Si s 4-26 IS-70. 00 o ��_ +��1� 1 /_L e+