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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL I ON AVE.; STOCKTON, CA Telephone 1209) 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. A" J Job Address �� City �' ' +t Lot Size 4O Ae r r_S PM Owner's Name 1 t Address /f 3:7 ,• k jffe / Phone 7 ` LI Contractor lkdo - &051_ Address s License No. Phone ` TYPE OF WELL/PUMP: NEW WELL ❑ 'WELL REPLACEMENT C1 DESTRUCTION ❑ r PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 4'INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ` f '-'-❑:Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑,Delta R Depth of Grout Seal Type of Grout ❑ irrigation _pprox. Depth �❑ Eastern f Surface Seal Installed by Repair Work Done ED/Type of Pump H.P. State Work Done Well Destruction-, E Well•Dia err Sealing Material (top 501 1-5)epth-"' Filler Material (Below 501 1 TYPE OF SEPTIC WORK:'%NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ jNo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial Installation Number of living units: -Number of bedrooms Character of soil to a depth of 3 feet: k-;� Water table depth SEPTIC TANK �f Type/Mfg _ Capacity_`g O No. Compartments PKG. TREATMENT,-PLT. ❑ �' '', � Method of Disposal Distance to nearest: Well_:Foundation �� Property Line /0 O Tr '`� O i LEACHING LINE 1'>�No4:&Length-of lines-=-r Y- Ts - Total length/size FILTER BED O, Distance to nearest: Well Foundation 0 Property Line SEEPAGE PITS 0-"�'Depth Size Number SUMPS ❑ Distance to nearest: Well b Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that"l have prepared'this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regu!atlons of the San Joaquin Local Health District. Home owner dr,licensed agent's-signature certifies the following: "f,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 1 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." The applicant must call for all a uired inspectio . Co plete drawing on reverse side. /£ Signed Title: Date: "� 7 t p FOR DEPARTMENT USE ONLY [ Application Accepted by Date tea, Area 5A4J' of Pit or Grout Inspection b Date Final Inspection by;4Date . �? inn b Additional Comments: ❑ Stk.,46Cr0781 _w .❑_Lod/ 3b21—❑-Menteca- - 104== ©*Tracy-»8354M38 . -,,. , Applicant- Return all copies to: Environmental Health Permit/Services 1601 Er Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE)-i°"AMOUITT DUE °'AMOUNT'REMITTE13CK H RECEIVED By— INN Y ~'' DATE PERMIT N0. INF �7 + EH 13-24 4REV.1/a 5) 7O r p� EH 14-28 �v v