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APPLICATION FOR.'PERMIT I' ' SAN JOAQUIN LOCAL HEALTH DISTRICT.,-- 1601 ISTRICT:.1601 E. HAZEL T ON AVE., STOCKTON, CA >„ ' Telephone (209) 466-6781 1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 4 (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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. titS14 Job Address t City � Lot Size 4X90 PM Owner's Nami e a LC-� Address Na 4 Phone Contractor -�TS�� L Address_ � ��• �-I4 �01` License No. ; Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ t DISTANCE TO NEAR EST:._SEPTlC TANK r'SEWE13_LIIVES,,� -- DISPOSAL FLD: PROP. LINE i ' FOUNDATION: AGRICULTURE WELL OTHER WELL PITS/SUMPS-� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS / ❑ Industrial `. ,. C] Open-Bottom—0-Manteca 0-Manteca Dia.-of-Well-Excavation Dia. of-Well Casing ❑ Domestic/Pfi ate ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1`1 Publici ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation-4 —.-Approx. Depth I I Eastern Surface Seal.lnstalled by Repair Work pone 17y `type of Pump f H.P. State Work Bone Well Destruction,- ❑ Well Diameter!) Sealing Material Itop 501 F , t Depth I Filler Material (Below 50'1 —_ TYPE OF SEPTIC-WORK: NEW INSTALLATION IL,�KEPAIR/ADDITION I .DESTRUCTION [ I (No septic system permitted if public sewer is W E 1' available within 200 feet.) Installation_will serve: ? Reis ence Commercial_ Other ; Number of living units: . Number,of bedrooms Character of soil,to a depth of 3 feet: b Water table depth _ SEPTIC TANK ❑ Type/Mf l n�1 C.1-' �-7tF Capacity No. Compartments PKG. TREATMENT PLT..❑ P+L CCN Cr F+ Method of Disposal i Distance to nearest: We Foundation Property Line LEACHING LINE. ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line X SEEPAGE PITS I I Depth 1 Size _ Number SUMPS lwi^w L�stance to nearest: -Well -�Foundation��-Propefty Line DISPOSAL PONDS 1 ❑ r' S 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 emploany person in such manner as to become subject to workman's compensation laws of.California."Contractor's hiring or sub-contracting signature certifies a 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 bk1c,alifornia.: pF The`'applican, t call fo all r Juireinsl t n n=1etrawing o averse sidb. /c Signed J� Title: Date: FOR DEPARTMENT USE ONLY Application Accepted,by Data Area Pit or Grout lnspection,by Date ° Final Inspection by,1��1 Date Additional Comments: ❑ Stk 466-6781 ❑ L".,.: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 a ---'"AMOUNT DUE'""`" AMOUNT REMITTLD— "' CK' "" RECEIVED`BY""' _M_DATE-r" _PEFirilllT kd: INFO r CASH. +-EH t3-241REV.ti/w5] F .r=' EH 14-28 C7 1 (�a Cr o —10 qi f ':I