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_ P APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT L// / f 1601 E. HAZEL T ON AVE., STOCKTON, CA v f, Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED j (Complete in Triplicate) h— Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the wor erem described. This app,cat,on 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. iy Job Address 1050 City Lot Size PM i; �)/� Owner's Name Address�if9� -1 �k, hc�G(1 `T 71 Phone Phone Contractor I Address f �.f� r, License NO:T7�d 3-X --Phone. 2T TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE Td NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE € FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Ria" of Well Excavation Dia. of Well Casing 4 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation —,Approx. Depth I I Eastern Surface Seal installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done_ O Well Destruction ❑ Well Diameter Sealing Material (top 50'1 F � v� Depth Filler Material (Below 50') TYPE OK SEPTIC WORK; NEW INSTALLATION 1:1 REPAIR/ADDITION I 1 DESTRUCTION Wo septic system permitted if public sewer is y i I' available within 200 feet.) Installation will serve: Residence Commercial..._ Other Number of living units: —2.0— Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANKType/Mfg "No.Compartments— PKG. TREATMENT PLT Method of Disposal _ 1 # Distance to nearest: Well Foundation Property Line LEACHING LINE I ❑ No. & Length of lines Total length/size E FILTER BED ❑ Distance to nearest: Well Foundation Property Line t SEEPAGE PITS ( I Depth Size Number SUMPS i t L7 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS } ❑ 1 I 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,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant ust II far all required inspections. Complete drawing on reverse side. ( 5 Signed X .11 !.Vy Title: Y Date: d w FOR DEPARTMENT USE ONLY Application Accepted by Data Area J`��j Pit or Grout Inspection b _ Data Final Inspection b Date�� Additional Comments: Cl Stk 466-6781 ❑ rod, 369-3621 ❑ M--(-ca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1501 E. Hazalton Ave., P.O. Bax 2009, Stk., CA 95201 tit- FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK 4 RECEIVED BY DATE PERMIT NO" t * + EH 13-24,REV.,/H5) 1 O EH a-26