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i Fig.-AP,PLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL—I ON AVE., STOCKTON, CA Telephone (209) 466-6781 r 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. 18152 for well/pump and the Rules and Regulations of the San Joaquin Local Health 10-0 S -� ►-� Job Address Cite Lot Size PM E Owner's Name""` ^a r f'`� Address 53 rvSa�4T h� a Or' G r vr, Pone � 11 ,�j t� ff I Contractor'Ern�-1 �J�sv S Address S—G � � D�L—i S l b 3y—�3 License No Phone TYPE OF WELL/PUMP: NEW WELL`'LT WELL REPLACEMENT D DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK I qo SEWER LINES DISPOSAL FLD. PROP. LINE� r FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIF CATIONS !f � ❑ Industrial ❑ Open Bottom_ ❑ Manteca Dia. of Well Ex cpy tion Dia. of Well Casing X Domestic/Private Q Gravel Pack ❑ Tracy Type of CasinSpecification 1 ElPublic O Other IN Delta Depth of Grout Seal Type of Grou on LJ Irrigation ---Approx. Depth 1-1Eastern Surface Seal Installed by� _ Repair Work Done ❑ Type of Pump j H.P. State Work Done Well Destruction ❑ Well Diameter . Sealing Material (top 50') Depth s Filler Material (Below 501 TYPE OF-SEPTIC WORK: NEW INSTALLATION ❑ 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: Water table depth SEPTIC TANK ❑ Type/Mfg ° Capacity No. Compartments PKG. TREATMENT PLT. Cl I Method of Disposal Distance to nearest: Well Foundation Property Line I i LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BEL) ❑ Distance to nearest: Well Foundation Property Line 4 SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance tonearest- 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 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 C ifornia." rE The applican �L&It calf for all eq ired inspections. Complete drawing on reverse side: Signed Title: Q �� aC,1 C. Date: T FOR DEPARTMENT USE ONLY Application Accepted Date �297 Area j� l Pit or Grout Inspection by T,.. Dae Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑Vodl 369-3621 ❑ Manteca 823-7104 Eftracv 835M85 Applicant-Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 y 71 FEE INFO AMOUNT DUE a AMOUNT REMITTED CA RECEIVED BY PATE PERMIT'N0. +EH1 3-24(REV.) 0 sr "�`�7