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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL'HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA �. Telephone {209) 466-6781 PERMIT EXPIRES'i'YEAR'FROM DATE ISSUED ' f r (Complete'injriplicate) 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. ' V 4 `U Me r. _.. _. _ eAJob Address _q1p O ' s City /A a-?t,4 Lot Size PM t 17 Owner's Name �Q y Address 9 - — /�a Phone Contractor J. Address Z�] license No. 029� 'I� Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION`;rj�, PUMP INSTALLATION ❑ SYSTEM REPAIR ❑- OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK /Od SEWER LINES DISPOSAL FLO.�(QQ PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELLS, PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing i' Domestic/Private X Gravel Pack Tracy Type of Casing Pye Specifications i ID Public ❑ Other 1-1 Delta Depth of Grout Seal .5� Type of Gra # ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump .H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 f TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ iNo septic system ystem 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 y No. Compartments PKG. TREATMENT PLT. ❑ I Method of Disposal } Distance to nearest: Well Foundation Property Line ' i LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well . Foundation Property Line • i I SEEPAGE PITS "❑ Depth Size Number 4 SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Thereby 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." i The applicant ynust call for all requi inspections. Complete drawing on everse side. w Signed Title: Date: O l O F013 EPARTMENT NLY � _ G c�' Application Accepted by.;--- r Date Area Pit orGrout Ir{spection 6(y Date '/"' 9 Final Inspection by _ Date 4 # Additional Comments: 'e2/�"C!� Y V CJS�/✓� �� sr ❑ Stk 466-67$1"' diodi t'369J3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Reiurn;1Il cdpies to:�EnAronmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 )NFO FEE— AMOUNT DUE AMOUNT,.REMITTED ASH RECEIVED BY DATE PERMIT NO.' Y} +EH 13-24.iREV.1/asl t (�j v - q&!L A - �S�� '�� f I1 EH 14.26 '`°