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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- :y (Complete in Triplicate) a 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. - 2 "Job Address �a:�+�� • � 4 � " v � �-7�- S! `City C Lot Size.. PM . Owner's Name - Address" . L'- " 741 _7W-4Sk Phone Ih r - '. Contractor Ix'I1G Address �' , License No. Phone " TYPE OF WELL/PUMP: �., F MEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION. ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ DISTANCE TO NEAREST: SEPTIC TANK OTHER ❑ r SEWER LINES DISPOSAL FLD. a PROP. L)t V' . j FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ,INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION"SPECIFfCATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of CasingDia. of Well Casing ❑ Public Specifications } ❑ Other [I Delta Depth of'Grout"Seal Type of Grout ❑ lirigation --Approx. Depth----{? Eastern Surface Sea nstalled b Repair Work Done ❑ Type of Pump 1'/ f r y W.P. H .• i r State Work Done Well Destruction ❑ Well Diameter 41, :.__41, Sealirig Material jltop'50') Depth ;1 Filler Material (Below 501) TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ ,REPAIR/,ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is a „r ., available within 200 feet.). z_ Installation will serve: Residence Commercial�,,Other i Number of living units : ' —L Number of bedrooms Character of soil to a depth of 3 feet: ` 1, SEPTIC TANK t j Water table depth ❑ Type/Mfg !=i Capacity No. Compartments 1 PKG. TREATMENT PLT. ❑ �y. { ' Method of Disposal \!" Distance to nearest: Well Foundation b Property Line�_ r LEACHINkLINE ❑,_;No. & Length of lines _ Total length/size FILTER BED ❑ Distance to nearest:-- -Well f d$ Foundation` Property..Line SEEPAGE PITS ❑ Depth J0 F-r— Size "T 'orf /O F7 Number SUMPS Distance to nearest: Well Foundation — I DISPOSAL PONDS ❑ r , ,et, •s� Property LineL ,_ ! 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:;"1 certify that in the performance of the work for which this permit is issued, I shall not a 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:"1 certify that in tfjla performance-of the wolrk-for which this-permit is issued, I-shall employ persons subject to workman's compensa- tion =aws of California.". l ` The 6pplicant must call for all re-Wired inspections. Complete;drawl g onreverse side. i Signed ; Title: j r : Date: ' — w FOR-DEPARTMENT USE'lONLY Application Accepted by /l � Area © � ' Date r Pit or Grout Inspection by Date " Final inspection by f � a Date Additional Comments: { ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 13T racy Applicant .836-6386 Return all copies to: Environmental Health Permit/services 1601 E. HazeltonAve., P.O. Box 2009; Stk., CA 95201 FEEi °" «•.-'�+-� INF�AMOUNT AMOUNI REMITTED CK#'" - CASH- �__ RECEIVED BY DATE PERMIT"NO.wEH 14-26