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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL'HEALTH DISTRICT r< , 1641 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDJ 0Z (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. j Job Address ll? 3 3 : ;` � C '� 1 City�1 Lot Size ;V,' 'PM Owner's Name _ " "Y/ '7h L-' � S- Address © ® -9, J -0-9" Phone - 2-012 Contractor q e L -if Address yt - - - License-.No. Phone i - 0 ,TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑'a SYSTEM REPAIR ❑ 1 OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK: SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION I AGRICULTURE WELL OTHER WELL PITS/SUMPS 4 INTENDED USE _.- TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS A ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 'Dia:of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy v Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation .,---Approx.-Depth—L1.Eastern Surface Seal Installed by o, Repair Work Done ❑ Type of Pump H.P. State Work Done T x E t Well Destruction ❑ Well Diameter • Sealing Material (top 501 -- ` Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is CU available within 200 feet.) Installation will serve: Residence✓ i Commercial Other -9 Number of living units: -/— Number of bedrooms t i $'F Character of soil to a depth of 3 feet: L o i[9 Water table depth SEPTIC TANK Type/Mfg I GD C Capacity MOO 44V_No. Compartments `+ PKG. TREATMENT PLT. ❑ i� Method of Disposal f Distance to nearest: Well -U Foundation��,� Property Line _ LEACHING LINE ❑ No. & Length of lines K / 0 Total length/siz 2, a FILTER BED ❑ Distance to nearest: Well Foundation .Property Line f � SEEPAGE PITS ❑ Depth Size -Number SUMPS ❑ Distance to nearest: Well Foundation _ Property Line 11 �] DISPOSAL PONDS t I a ?�.• . I hereby certify that I have prepared this application and that the work will begone in accorda-fte with San Joaquin county ordinances, state laws, arid 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- g. I tion laws of California." ' The,applicant must rWI. required inspections-Complete drawing on reverse side. Signed ' Title: date: E 1 R DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: s t s ❑ Stk 466-6781 L-2-11odi 369 1 Manteca 823-7104 ❑ Tracy 83&6385 Applicant- Return all copies to: Environmental lqeahh Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I�I FEEAMOUNT DUE ° AMOUNT REMITTED RECEIVED BY. DATE PERMIT`NO. INFO C + Eli-13-24(REV.7/s EN 14-26 J -