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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT \ 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 3u 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 `f7.3 -3 ///a Z-5- s City Lot Size "7_VX)vr PM Owner's Name d .4 A Address Phone 12- Contractor Eta Y'D E.LoeeD Address 7. V. 14,0E Ld e,,�_7+ E License No. ��-L�Y�L _Phone '3°I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ r SYSTEM REPAIR 71rOTHER ❑ I DISTANCE TO NEAREST: SEPTIC TANK SEWER.LINES.+,''.-- DISPOSAL FLD. + PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL I PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Neil Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F] Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation W._..Approx. Depth l I Eastern Surface Seal installed by t F Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material 18elow 50'1 �VV TYPE OF SEPTIC WORK: NEW INSTALLATION I.) REPAIR/ADDITION DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial— OtherP�( g/–I, W A 7145-f-, . .�. !Number of living units: -_-/ Number of bedrooms Character of soil to a depth of 3 feet: �' L Ay _ Water table depth A 4 SEPTIC TANK ❑ Type/Mfg .=y tc rnnCG 2 CapacityNo. Compartments i PKG. TREATMENT PLT. ❑ Method of Disposal n Distance to nearest: Well Foundation Property Line r ` 3 LEACHING LINE No. & Length of lines :A4 V Total length/size FILTER BED ❑ Distance to nearest: Well N— Foundation 7-dr Property Line 10` SEEPAGE PITS iK-,Depth -Size 3 3. f/ Number H SUMPS L1 Distance to nearest: ,,,WellAVA Foundation 70' 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 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 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 call for all required inspections. Complete drawing on reverse side. Signed x Title: __ Date: f B FOR DEPARTMENT USE ONLY r� Application Accepted by Date T Area �— Pit or Grout Inspe tion b Date Final Inspection by n Date l� Additional Comment ❑ Stk 466-6781 odi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all opies to: Environmental Health Permit/Services 1601 E..Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i FEE AMOUNT DUE AMOUNT REMITTED CK H RECEIVED BY DATE PERMIT NO. INFO `'7 // +.EH 14-24IpEV.iiHs) Z O,o o t7 /3 �! L? CIO`- EH 1428 J i