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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.549 for sewage or No. 1$62 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. G I I f Job Address I a 1 r � _�A�� LE City Lot Size 110 1 X 1 ! Owner's Name 115A Address ', . 56PhonL 13 $7T" Z P/ 77210-4� � Contractor [V aC-! Address J� \ License No. Phone TYPE OF WELL/PUMP: �I NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION 45 AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS yndustrial r."Gravel pen Bottom ❑ Manteca Dia. of Well Excavation I t/1, Dia. of WBII Casing � 1 Domestic/Private Pack, ❑ Tracy Type of Casing- 1� S pecifications ❑ Public ther �o�+ o✓ C] Delta Depth of Grout Seal Type of Grout ❑ Irrigation pprox. Depth ❑ EasternSurface Seal Installed by Y al C_ Repair Work Done ❑ Type of Pump H.P. State Work one Well Destruction El Well Diameter I Sealing Material {top 50') �— Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is I � available within 200 feet.) ` Installation will serve: Residence_ Commercial— Other O Number of living units: I�, Number of bedrooms ✓�~ Character of soil to a depth of 3 feet.- Number eet: ` Water table depth SEPTIC TANK ❑ Type/Mfg -apaci / No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to near t: WeII� Foundation Property Line I ,� LEACHING LINE 'F - ❑ No. & Length of lines Total length/size FILTER BED ❑ Sistance to nearest: Well Foundation Property Line �M SEEPAGE PITS ❑ Depth Size SUMPS Number ❑ D` istance 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 sub-contracting signature certifies 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 compensa- tion laws of California." M / pensa The applicant must call for all lequired ins coons. Complete drawing on reverse side. ' �I /�O!<llIC1�l Signed 0 1 kJ��_,_Q�� Title: � _ Date: NT USE ONLY t t of P F /k Applicatioh Accepted by-', ii Date Area I Pit o,�,r Grout Uispe i y I Jnspection by 1/ 4 Date,4—_Z —Qfra Additional Comments: ❑FStk.1-'i8.=6781', y'I ;❑.L 41., 1 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Appllicant,, all copies-to, Environmen Return tal Health Permit/Services 1BD1 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 c..{:_ .gyp 1..e. :.�nn:I I� FEE h INFO AMOUNT DUE AMOUNT REMITTED C RECEIVED BY DATE ZPERMIT"No. EEV.24 IRI/a 51EHH M1428151••5 ,- ; �"