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} a k x APPLICATION FOR PERMIT �� SAN JOAQUIN LOCAL HEALTH DISTRICT )` 1601 E. HAZEL T ON AVE., STOCKTON, CA a Telephone (209) 466-6781 1 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 Y aquin County Ordinance.No.549 for sewage or No. 1862 for well/pump �af d the/Rules and Regulations of the San Joaquin Local Health District. Job Address yL% I� 9, &,y/ City t" Lot Size PM Owner's Name/0�7�n�l��! V -- Address /X �S , 06)e-! _- Phone Contractor �M Address License No. Phone TYPE OF WELL/PUMP. .I�. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ .•F DISTANCE TO NEAREST: SEPTIC TA SEWER LINES FOUNDATION AG E WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WE ROBLEM AR INSTRUCTION SPECIFICATIONS ElIndustrial ❑ ottom ❑ Manteca Dia. of a ation Dia. of Well Casing ❑ Domestic/!viva ❑(Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout F1 Irrigation -Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done r Well Destruction ❑ Well Diameter Sealing Material (top 501 ((�� Depth Filler Material (Below 50') y' TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIO (No septic system permitted if public sewer is .11 vailable within 200 feet.) Installation will serve: Residence_ Commercial— Other i- Number of living units: �� Number of bedrooms T k Character of soil to a dept)bf 3 feet: .. Water table depth n a SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ r Method of Disposal i Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines ? Total length/size T FILTER BED ❑ Distance to nearest: Well Foundation Property Line l ) SEEPAGE PITS ❑ Depth Size F Number SUMPS ❑ 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 rules and regulations of.the �an 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 signatur 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." k The applicant must call for all required inWections. Complete drawing on reverse side. Signed Title: Date: ZA FOR DEPARTMENT USE ONLY Application Accepted by �i X_ Date �U Area a� I 'f Pit or Grout Inspection ® Date Final Inspection by Date Additional Comments: •"wl1L�/, ®�� ❑ Stk 466-6781 ❑ Ladi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies' o: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 k ' r FEE AMpUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. r INFO x r b + EH 13-24(FEV.t i e 5) - Qe� _773 �� EH 1426 # M h 1�'