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APPLICATION,FOR PERMIT Uv�f ` SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES i 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. Job Address City Lot Size _ f U a _ PM Owner's Named W AOS162 /� Address ��i9� � Phone .31'- r i Contractor's Name ��2/f/S` 94_d`6S License No. IS-y_",3cj3 Phone £ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ i I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS = 4 INTENDED USE TYPE OF WELL tPROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ;❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel_Pack ,CJ Tracy Type of Casing Specifications ❑ Public ❑ Other I❑ Delta Depth of Grout Seal Type of Grout 'Y-Irrigation --4pprox:-Depth ❑ Eastern Surface Seal Installed by (� F -Repair Work Done ❑ Type of Pump H.P. State Work Done Weli'Destruction �❑ -W&II'Diameter Sealing Material (top 501 DepthFiller Material (8alo TYPE OF SEPTIC WORK: NEW INSTALLATION [t] REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is t available within 200 feet.) Installation will serve: Residence Commercial, Other s �\ Number of living units:-/— ,Number of bedrooms 7 Character of soil to a depth of 3 feet: e-4/F Y _ F Water table depth ezy1 SEPTIC TALK ❑ Type/ Mfg Capacity No. Compartments `•, PKG, TREATMENTIPLT. ❑ t Method of Disposal Distance to nearest: Well Foundation Property Line t F LEACHING LINE Na. & Length of lines dotal length/size a FILTER BED i ❑ Distance to nearest: Well�� Foundation /(�_ Property Line SEEPAGE PITS L7 Depth _Size Number SUMPS ❑ Distance to nearest: Well AIA Foundation Property Line DISPOSAL PONDS ❑ e 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 r agent's si nature certifies the following:9 9 g: "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.—"Contractors-hiriAg-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." i The applicant call for all required inspections. Complete drawing on reverse s' 1 r , _ Signed Title: ti* ,Date: I7 e FOR DE PAR N SE ONLY Application Accepted by �( _ Date Area. t Pit or Grout Inspection by Date -X Final Inspection by Date } Additional Comments: i ❑ S1tk--466-6M-----2-6o&--369.382-1...- ❑_Manteca-823-7:04----I]=Tracy--835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 E FEE AMOUNT DUE AMOUNT REMITTED'` Y RECEIVED BY DATE` PERMIT"NO. I NFO CASH + EH1&24(REV,10M) EH 114-28 L 0