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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 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 Ryles and Regulations of the San Joaquin Local Health District. Job Address , City Lot Size 6� PM �zOwner's Name � o ��X13-� Address � e" _ �Je-LDy�4_ .Phone Contractor u�✓ !' i s Address 4. 4 ' License No. . Phone TYPE OF-WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 07HER ❑ DIS TANCESTO NEAREST: SEPTIC TANK SEINER LINES DISPOSAL FLO/ PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ` INTENDED USE TYPuOF,WELL_._N," 'PROBLEMAREA CONSTRUCTION SPECIFICATIONS ❑ Industrial '❑-Open-Bottom "EI'Manteca_. ,_ .,Dia fof Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth .-❑,Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump ti `` '+'" H.PState Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') U Depth I Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW-INSTALLATION ❑ `REPAY / DDITIGN- --DESTRUCTION Cl-(No septic system permitted if public sewer is G '/ i available within 200 feet.I ) ,AitaElatiomwill,serve: Resident Commercial— Other Number-of living units t'" s Number of.`bedroo ss Character of soil to a depth of 3.feef. Water table depth Ax SEPTIC TANK ❑ Type/Mfg ! 'I` ," Capacity ' No. Compartments PKG: TREATMENT,PLT. ❑ I Ii fL els j Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines .` Y, Total length/size FILTER�ED '�( Distance to nearest: 9 Well 946' Foundation— IC)r Property Line_g- SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Prop&I:Y 6ne� 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 forI req " d inspections. Complete drawing on reverse side. i Signed Title:_ - . Date: fir FOR DEPARTMENT USE ONLY Application Accepted by �� ' � Date Z Area Pit or Grout Inspection by Date Final Inspection by Dat z Additional Comments: 6'tk 46Co% El Lodi 369-3621 El Manteca 823-7104 ID Tracy 835-6:385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT"N0: a EH1 _AU � 3-24 MEV.I/a 5) - EH 1426 � 3S �S-..13 9