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M APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone 12091 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 �S S� kLI 61% 7 L City 11602g2c2V Lot Size PM Owner's Nam Address S &,4169 -MhU AA- Phone Contractor Address License No. _ Phone r '! TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ �1 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHERN16idlTaxrnla DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. 7PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ndustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 21 0 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing,S['4 �f� Q✓{ - Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ElIrrigation --Approx. Depth F1Eastern Surface Seat Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') — TYPE OF SEPTIC WORK: NEW INSTTION ❑ REPAIR/ADDITION EJ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Co ercial_ Other Number of living units: Number of bedr s Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg ZI Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: We14 Foun on 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, I shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or subcontracting signature certifies the following: "I cern 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." f The applicant must caall required ins ct,ons. Complete drawing on reverse side. Signed Title: -IkPriz��raC� �PMJSowI Date, S r:. FO EP SE ONLY Ap caepted by Date � "—Wea ' , ( Pit or G7, 1pe i by Date-� Final Inspection by Date 1 i Additional Comments: ❑ Stk 466-6781 ❑ Ai 369 1 Manteca 844f04 ❑ Tracy 8354KMi- Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA491.- FEE 1 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO + EH 13-24(REV.i/65) EH 1428