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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON,' CA Telephone {209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATEIISSUED • At (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 8W Ebst yettiffM Tate City Lcdi Lot Size PM Owner's Name IBM PYC S Address P.Q. BCK 5811► Sm Matm Phone 415-571-2434 Contractor Egm1tm1 Address icense No. 596545 Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ VEPCJ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK >50 ft SEWER LINES >50 ft DISPOSAL FLD. >50' PROP. LINE 1� FOUNDATION 210r AGRICULTURE WELL � OTHER WELL >50t)I PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial Cl Open Bottom 11 Manteca Dia- of Well Excavation Dia. of Well Casing 411 ❑ Domestic/Private 1 Gravel Pack ❑ Tracy Type of Casing M Specifications I-) Public ❑ Other ❑ Delta Depth of Grout Seal 81 Type of Grout13�I�SI71�_. I 1 Irrigation —.-Approx. Depth IN Eastern Surface Seal Installed by trlllt T Repair Work Done ❑ Type of Pump M H,P. State Work Done Well Destruction C Well Diameter 4rn Sealing Material {top 50') bE ±CriiWcaf1it SLurj37 EKLrc_CdMDepth 251 Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I.) REPAIR/ADDITION l 1 DESTRUCTION { I (No septic system permitted if public sewer is O available within 200 feet.) Q 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 n PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line ` LEACHING LINE ❑ No. & Length of lines 9 Tota! length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line v SEEPAGE PITS l I Depth Size 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 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 taws 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." The applicantm II for all re fired inspec ions. Complete drawing on reverse side. Signed X Title: Pm�a"'t G3D1Cgst Date: t' 1 loi9e K. Frkk FOR D 7MENT ONLY Application Accepted by ! Date Area Pit or Grout Inspection by L� Date fl-1 Z ! Final Inspection by 't'` Date? Z �? Additional Comments: ❑ Stk 466.6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 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 CKA CASH RECEIVED BY DATE PERMI7'NO. +.EH1 -24{gEV.FiNel EH 14-26