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APPLICATIOAI FOR�''f ERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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. l - ,t r ^ �,` l Job Address � 191 "��t��° � City ��`�C� Lot Size �Oyku e PM 1�(ZtS � �CfL o 27 IR 9,A X23 85�� Owner's Name M Address � Phone Contractor_ 1 r � Address SO I�UTi_6-4J _ icense No.29 1 a Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ I PUMP INSTALLATION El SYSTEM REPAIR L7 OTHER ❑ I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS I INTENDED USE TYPE OF.WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom y ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack i❑ Tracy Type of Casing Specifications I'l Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout _ I I Irrigation --Approx. Depth i I Eastern Surface Seal Installed by _ Repair Work Done L1 Type of Pump H.P. State Work Done_ k Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material IBelow 50'1 —_ TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION { DESTRUCTION i I (No septic system permitted if public sewer is { 7 - - — -- - • - - I . .. available within 200 feet.i Installation will serve: Residence _ Commercials=Other { E Number of living unit;j� Number of bedroomsM Character of soil to a depth'nf 3 feet: Water table depth SEPTIC TANK ❑ Type/-Mfg / Capacity - No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: ` Well FoUhdation-"' ' Property Line LEACHING LINE &5*,*-No. & Length of lines' f Total length/size f �' FILTER BED ❑ Distance to nearest: Well µ Foundation Property Line SEEPAGE PITS w`I I Depth 'r Size Number r SUMPS { ❑ Distance to-neerest Well '""^°'" Fb dation''"P Property Line DISPdSAL 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-Distfict:- 4. - Homeowner 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." } dd The ap¢.Iican .Mu&Lcall fora quired ins tions. Complete drawing on reverse side. s y r r f(�- �,tom- ' 0 9n Signed X �`' Title: Date: OR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by ate--2 U Additional Comments: ...- G-Stk-466.6781 E7-L-odi-369=3621-----fl•Manteca=- 823-7484 E9-TTacy-835-6365 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009,..Stk-, CA 95201 IEEENF% AMOUNT DUE ° AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'No. +.EH 13-241REV.v/n51 0 J , 0 EH 14.29