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APPLICATION FOR PERMIT PAyME � SAN JOAQUIN LOCAL HEALTH DISTRICT RECEIVED 1601 E. HAZELTON AVE., STOCKTON, CA 1987 Telephone (209),466-6781 � . PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) ENVIRONMENTAL HEALYH PERMITISERYICES Application is hereby[Wade to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is 9 made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for welUpump and the Rules and Regulations of the San Joaquin Local Health District. 17, �V.7 4 Job Address 10100 f-v r 6u00 City Lot Size PM 3 3-7 Owner's Name _��' /� � Address t Phone ^7 Zc Contractor j��1�Q� {J-Address �y � �i✓e 0� icense No. �? SS�2— Phone TYPE OF WELL/PUMP: NEW WELL � WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ y SYSTEM,REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK`-" Q f SEWER LINES � DISPOSAL FLD. PROP; LINE 3!1 FOUNDATION .__-. J.._L AGRICULTURE WELL, � OTHER WELL �- - ,PITS/SUMPS-"– INTENDED USE T TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r Ci Industrial I XOpen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing KDomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F1 Public f 1711Other 1-1Delta Depth of Grout Seal ' . D `T e of Grout _. I I Irrigation —.-Approx. Depth I 1 Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H,P. State Work Done Well Destruction 0 Well Diameter Sealing Material [top 501i Depth Filler Material Below 50'i TYPE OF SEPTIC WORK: NFW INSTALLATION i 1 REPAIR/ADDITION I I DESTRUCTION i,l' INo`septic`system permitted if public sewer is available within 200 feet.l Installation will serve: Residence= Commercial_ Other 1 f f Number of living units: Number of bedrooms r Character of soil to a depth of 3 feet: L Water table depth SEPTIC TANK i ❑ Type/Mfg Capacity --No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation 4 Property Line LEACHING LINE- ❑ No. & Length of lines Total length/size i r FILTER BED Q Distance to nearest: Well zf<unclation Property Line SEEPAGE PITS I I Depth Size mber SUMPS t 1:1 Distance to nearest: Well Foy ation Property Line DISPOSAL PONDS C3 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. 1 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 became 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 perm is issued, I shall employ persons subject to workman's compensa- tion laws of Califor ia." The applicant m I for aired i cti omplete drawing on reverse side:'' Signed X It e:__...-.-. DateJ 6-142 E � FOR DEPARTMENT USE ONLY s I aJ 1 J 'ted`� f Application Accepted by Date 4 � AC)rea�� Pit or Grout Inspection by Date ' 1 / Final Inspection by I Date 001 Additional Comments: _ I Cl Stk 466-6781 r...... O'Lodl 369-36_l ❑ Manteca 823-7104 ❑ Tracy 635-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601;E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE I . I INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'NO. /� r + EH 13241REV.i/e51 U O `I EH 14-28 i