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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE,, STOCKTON, CA Telephone (209) 466-6781 �- r PERMIT EXPIRES 1'YEAR FROM DATE ISSUED 1 (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 70 dF City Lot Size PM r Owner's NameA L1Gi/ Address �!�/ 5G'�+'itf - Phare ContractorMEGoc- # Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FED,` PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS mac• INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack l] Tracy F� Type of Casing Speci#icatians t ( i Public C7 Other 171 Delta f k Depth of Grout Seal Type of Grout _ E I Irrigation _-Approx. Depth l I Eastern Surface Seal Installed by }� Repair Work Done ❑ Type of Pump H.P. State Work Done De Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth ' Filler Material (Below 50'1 , TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION i I DESTRUCTION (No septic system permitted if public sewer is 1 available within 200 feet.) Installation will serve: Residence Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: + 1 f Water table depth SEPTIC TANK EJType/Mfg Capacity No. Compart6nts PKG. TREATMENT PLT- ❑ 1 Method of Disposal ' Distance to nearest: Wel! Foundation Property.Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED v ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS f 1 Depth Size Number SUMPS ❑ Distance to nearest: Well, Foundation Property Line DISPOSAL PONDS ❑ I 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 hiringor 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." The applicant must call for all required inspections. Complete drawing on reverse side. JL Signed X -, _ Title:-Al GU!/`�i� .. Date: FOR DEPARTMENT USE ONLY Application Accepted by Cs') Date_y =Ag LSo^— 1 Area _ Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Ad / Q Stk 466.6781 ❑ LoAi 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 INFO �7 r�CA3H RECEIVED BY ED7A;TE PERMIT N0. +.EH 14-24(REV.t i n 5f �� S ( l,Fj`2 ! /1 EH 14.26 ( VJ /�[/