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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 r (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 a City Lot Size PM Owner's NameALT Address Phone :Ip , wr��Fe sysr�zs Ch! Contractor's Name1�/U'T License No. '9��rS'��l Phone TYPE OF WELL/PUMP: II NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION JW?,SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE pQ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS x ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia, of Well Casing ,*Domestic/Private I] 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 LIS H.P. State Work Done ..i. Well Destruction 11Well Diameter Sealing Material (top 50') 5A46? �U DepthFiller Material (Below 501 TYPE OF SEPTIC WORK: NE-N_STALLATION ❑ REPAIR/ADDITION ❑' DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: {Z IWater table depth SEPTIC TANK ❑ Type/Mfg - I Capacity I No. Compartments PKG. TREATMENT PLT. ❑ IN . I 9 Method of Disposal Distanc8-it�rresrest;—�Wdll� Foundation, Propehy Line LEACHING LINE ❑ No. & Length of linesr*� l Total length/ ize FILTER E BED ❑ Distance to nearest: Well Foundation_� Property Line I� ff SEEPAGE PITS ❑ Depth Size Number 1 SUMPS ❑ Di4ance to nearest: Well Foundation ! Property Line DISPOSAL PONDS ❑ ! I 1 I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, stat laws, and rules and regulations of the San lJoaquin Local Health District. i I 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 mannas as-to-become.subject-to-workman's-compensation-laws of Cal4rnia."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 Vshall employ persons subject to workman's'compensa- tion laws of California." l f If. Ij The applicant m fo all re re inspections. Complete drawinyg� on reverse_e. Signed X /_/{/Li�� ^'Title ti i��/s� l_i -dz� `Date: 3 '- i FOR DEPA ENT USE ONLY�6 t�cA�+. Application Accepted by v v Dater: I Area CT Pit or Grout Inspection by II Date Final Inspectiohrby `r, nn Dates-�, � Additional Comments: I� + +? f ❑-Stk 4W6781 ❑-todi.13693621 ❑-]Manteca-8237104 ©Tracy-835r6385v^ —�— 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 CASH RECEIVED BY DATE PERMIT"NO. EH 1426 r EH 13-24(REV.101831 S I�O1 1�7, , 1� - ,