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r 4 APPLICATION FOR PERMIT �* x SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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 Distrito. Job Address / / city Lot Size t A�' PM Owner's Name Address `� ` �"� Phone 369- 7162 a - j Contractor W`Wf!Address l�sl' S7oCA21% 4��License No. 30s;W Phone TYPE OE WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ T PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO 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 Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public Cl Other F1 Delta Depth of Grout Seal Type of Grout _ I I Irrigation A _Approx. Depth l I 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 IBelow 501 P 2.. TYPE OF SEPTIC WORK: NEW INSTALLATION ILL-' REPAIR/ADDITION I I DESTRUCTION I 1 (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence &__'Commercial— Other Number of living units: Number of b Brooms� Character of soil to a depth of 3 feetI Water table depth d SEPTIC TANK E9' Type/Mfg e6� - .(LICapacity 100 ° No. Compartments PKG. TREATMENT PLT. ❑ l Method of Disposal f Distance to nearest: Well Foundation l� Property Line Q LEACHING LINE Er-No. & Length of lines C3 _ F t Total length/size FILTER BED ❑ Distance to nearest: Well i Foundation ��l Property Line F SEEPAGE PITS 14--Depth alb r Size 3 y Number SUMPS 0 Distance to nearest: Well Foundation f Property Line l 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, ander rules and regulations of the San Joaquin Local Health Diltrict. i Home owner or licensed agent's signature certifies the following: ",l certify thatln 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 compansation 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 must call for all equired inspections. Complete drawing onn}rever side. Signed X Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pita Grout Inspection by Date Final Inspection by V_"bata Z-3— 1 dditional Comments: ❑-Stk-466-6781--------LI-L-odi--369-3621 0 Manteca- 823-7104 -- ❑ Tracy-835-6386 Applicant - Return all copies to: Environmental.Healih Permit/Services 1601`E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK 9 CASH RECEIVED BY DATE P(/E�RiN11T'No. +.EH14-26IREV.t/n5) �.t, 7 �pr� �. � 67�l��