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-#17 APPLICATION FOR PERMIT f 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 t made in compliance with San Joaquin County Ordinance No.549 for sewage or No.j1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address (_i City Let Size PM Owner's Name " i f Address 7yu2yJ=7 (JfC Phone 3�L r 3`� Contractor 5 !'/�—Ipddress !a�� fs( �� cense No.Q7 '7FI7'7FPhbne364 3 13 TYPE OF WELL PLhM NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR U?1, OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE + FOtJ.NDATION_ _ AGRICULTURE WELLS _ I --- , -� OTHER_WELL,— __PETS/SUMPS - INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca ,,��bia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications FI Public 171 Other Cl Delta �?epth of Grout Seal Type of Grout t Irrigation _-.Approx. Depth hl Eastern - ,r"�urface Seal Installed by Repair Work Done ❑ Type of PumpT H.P.!'*d} State Work Done C U C,T " Well Destruction ❑ Well Diameter .7_ _ Sealing Material Itop 50'1 D I! $ J Ju `. Depth Filler Material [Below 54'I r TYPE OF SEPTIC WORK; NEW INSTALLATION I J REPAIR/ADDITION I I DESTRUCTION i I (No septic system permitted if public sewer is available within 200 feet.) { Installation will serve: Residence_ Commercial_ Other —1 ... Number of Iivirig units - N4ttlher_of-bedrooms.-- Character of soil to a depth of 3 feet: . t Water table depth - SEPTIC TANK ❑ Type/Mfg Ca acit p Y No. Compartments PKG. TREATMENT PLT. ❑ futetho t Distance to nearest: Well Foundation Property Line " '�+_ LEACHING LINE ❑ No. & Length of lines Total length/size IVED krli FILTER BED ❑ Distance to nearest: Well FoundationPropert Line AN JuxQuTntOUNTY l 100E , SEEPAGE PITS 13 Depth Size Number t, ' ERS SUMPS Ll Distance to nearest: Well Foundation Property Line �DIS.POSA!_PONDS ❑. ---- - -. _. _- _ _ - -- ---°�`� I hereby certify that I have prepared this application and that the work will be done in accordance;with San Joaqu n.cbunty nance ,state laws, ordisjAA( rules and regulations of the San Joaquin Local Health District. F ' Home owner or licensed agent's signature certifies the following: '9 certify that in the performance of the work fort wHicfl this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contracto s hiring or sub-contracting signature certifies the following: "I certify tion laws of California." that in the performance of t work for which this permit is issued, I shall employ par pns subject to workman's compensa- t The applicant must call all required inspections. Complete drawing on reverse side. Signed X Title: k � _Date: _2- FOR DEPARTMENT USE O LY Application Accepted by Date �_Z :Z `Z-- Area Pit or Grout Inspection by Date Final Inspection by.--� �;,✓ /•'1�p�l�LJrl Date Z Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 } FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY INFO CASH DATE PERMIT'NO. EH t1-2e a.EH 14-291REV.FiN5) }