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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.548 for sewage or Na.1862 for well/pump and the Ryles and Regulations of the San Joaquin Local Health District. j I , e. '111 ~ ' 1 Job Address __�� ! 11 r �5 // NeIAJ Cityj y Lot S/iz�e� �3PM / Owner's Namo' AIAE__ ,49 _ Address 1�OX �.7L} Thfi✓iLfO�' �� ip Phone Contractor 5�41= Address License No. - Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FUD. PROP, LINE _ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑Other ❑ Delta •Depth of Grout Seal Type of Grout _ ❑ Irrigation _Approx. Depth ❑ Eastern Surface Seal Installed by ` k Repair Work Done ❑ Type of Pump H.P. State Work lions Well Destruction ElWell Diameter (t. Sealing Material (top 50'1 '"1 Depth Filler Material{Below SO') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ Mo septic system permitted if public sewer is • installation will serve: Residence-IL Commercial_ Other available within 200 feet.) Number of living units:-4-- Number of bedrooms I_ 'f,+.. Character of Will to a depth of 3 feet: Water table depth -SEPTIC TANK Type/Mfg opacity I •t No. Compartments PKG. TREATMENT PLT.❑ / Method of Disposal Distance to nearer[: Well T"SU Foundation Property Una n � -'_)LEACHING LINE !9 No. & Length of lines Total length/size 96/ 4 FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number 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, 1 shall not employ any person in such manner as to become subject to workman's compensation laws of California."Convector's hiring or sub-contracting signature certifies the following:"I cartify,that in the perfornance of the work for which this permit is issued,I shall employ persona subject to workman's compensa- tion laws of California." The applicantu cgYiq I r quired inspections. pill drawing an reverse side, p z� p Signed , C 4f'/ Ti ie: .... Date: FOR DEPARTMENT USE ONLY Application Accepted by Date 'y Area Pit or Grout Inspection byDate Final Inspection by Date Additional Comments O� ❑ Stk 4666781 ❑ L r 369.3621 ❑ Mamt. 823.7104 ❑ Tracy 8366385 • Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave.,P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMnTEO INFOJ� CASH RECEIVED BY DATE PERMIT-NO. .EH 13-23(REV.1/e s) ,�E•}- EH 1476