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APPLICATION FOR PERMIT 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 4weby made to the Sar, 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. 2 2 � y /, ��q��p/'� '� /� C .lob Address __��aL��.11_I-��.--�d`(� City ��v�_ Lot Size L_N t PM Owner's Name I k. Address Address ._ _-_ ___ Phone Contractor t" t- 1 r �M Address_J I`�d� License No. VS Phone y�—t�✓r TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR £7 OTHER601 1 DISTANCE TO NEAREST: SEPTIC TANK -J_3Q1— SEWER LINES ��O— DISPOSAL FLD. PROP. LINE FOUNDATION —� t AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I Industrial Cl Open Bottom D Manteca Dia. of Well Excavation_ Dia. of Well Casing Domestic/Private Gravel Pack D Tracy Type of Casing_ e Specifications W ii Public I_l Otplt�'r 11 Delta Depth of Grout Seal IQo I Type of Groutt'( n I I Irrigation Fc2P1prox. Depth I I Eastern Surface Seal Installed by — Repair Work Done (J Type of Pump H.P. _ State Work Done Well Destruction O Well Diameter Sealing Material (top 561 111 Depth Filler Material (Below 59) TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is 'available within 200 feet.) Installation will serve: Residenoe_._ Commercial____ Other Number of living units: ___ Number of bedrooms _ ____ C Character of soil to a depth of 3 feet: ------- Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. D Method of Disposal Distance to nearest: WMI .- Foundation. Property Line LEACHING LINE Ll No. & Length of lines _ Total length/size FILTER BED f I Distance to nearest: Well Foundation _ Property Line SEEPAGE PITS I I Depth Size Number _ SUMPS I 1 Distance to nearest: Well_. _ Foundation_ _ Property Line DISPOSAL PONDS I 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 Di§trict. Horne owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 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 ,)ertifies 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 compensd tion laws of California." The applrcant-TIfi6'st call for all required in tions. Comple drawing on reverse side. Sinned X. z L 7`-�+ - — Title: --- J - -- Date: 3 r2 `_q FOR DEPARTMENT USE ONLY I Application Accepted by .. �� _$.Ae pefe ,• _ Arae— PitOK,( rout I pection by y Date �� k FinallrInspection by — Date Additional Comments: ' O o f0/�i L1—/�y� J+�iJ�Q �/ eZ3j/ 1:1 Stk 466.6781 1 Manteca R23 'I_l Tracy 835- xori,_ Applicant Return all copies to: Environmental Health Permit Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CA K RECEIVED BY DATE PERMIT NO. N � 0 1 ('7 O 3^OSos t1 1l 14 2„ntro ,:Ms, P �-- i y1/ 73�� - o b