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' APPLICATION FOR PERMIT SAN JOAQUIIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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 ls-� �',Y�' lee City Lot Size C PM Owner's Named�lC� Address Phone Contractor xyrty /""may G"? Address '1r� �dP`'7�� License No. 5 � 1 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR E] OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE /-TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS % ❑ Industrial [n Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout . I ]'Irrigation --Approx. Depth 1.1 Eastern Surface Seal Installed by _ `J Repair Work Done ❑ Type of Pump H,P, State Work Done C Well Destruction ❑ Well Diameter Seating Material Itop 50') P Depth '' 'Filler Material (Below 50') - Y TYPE OF SEPTIC WORK: +NEW'INSTALLATION 1.) REPAIR/ADDITION DESTRUCTION 1 1 iNo septic system permitted if public sewer is available within 200 feet.) Installation-will serve: Residence_ Commercial___.- Other ,Number of living units: A y Number of bedrooms Character of soil to a depth of 3 feet: Water t:i ,depth SEPTIC TANK ❑ Type/Mfg Capacity --No. Compartments I PKG, TREATMENT PLT. ❑ Method.of Disposal Distance to neatest:----Well --- •Foundation Property Line v e' LEACHING LINE No. & Length of lines 2 d /�% Total length/size.- FILTER BED ❑ Distance-lo nearest: Well i' Foundation -�= Property Line -� SEEPAGE PITS LI Depth _ Size Number �- SUMPS 0 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 i ! rules and regulations of the San Joaquin Local Health District. 3 Home owner'or licensed agent's signature certifies the following: "1 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." The applicant must ca II r uire spe Complete drawing on reverse side. r' Signed X { Title: Date: FOR DEPARTMENT USE ONLY t Application Accepted by bate � Area Pit or Grout Ins ' [-- pection by Date Final inspection by r _ Date 'l ' Additional Commen . � ❑ Stk 46fi-6781_C7'C6clf 389-3621 ❑ Ment 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to:,Environmental Health Permit/Services 1601 E. Hazelton Ave„ P.O. Box 2009, Silk., CA 95201FEE y�r INFO .eAMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. s' ♦ EH13-24 IRE'V.1 i H s) `a(r�r��c..�} O r� 4 z2 EH 1426 ` C 1 2� I V-7 "� J7o