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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT I 1601 E. H AZE.,I•N AVE., STOCKTON, CA j Telephone (209) 466-6781 JUL 1 '15' 1904 PERMIT EXPIRES 1 YEAR FROM OATS ISSUED (Complete in Triplicate) EA, JMQU ° LOCAL [«4�JhL� .,. : . 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. Job Address G _ City Lot Size PM Owner's Name ' A - �� Address Q U Phone%? — u r Contractor's Name License.No. 3 Phone `��or-f TYPE OF WELL/PUMP: y rNEW WELL 11 WELL REPLACEMENT ❑ DESTRUCTION ❑ 01 --�---PUMP-INSTAL-LAT-ION--L7=--f--•-r------. -SYSTEM-REPAIR-J;;i---___ --. OTHER-p.. 0 DISTANCE TO NEAREST: SEPTIC TANK i SEWER LINES DISPOSAL FLD. PROP. LINE l FOUNDATION AGRICULTURE WELL OTHER WELL - PITS/SUMPS a INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing - El Domestic/Private D Gravel Pack ❑ Tracy ': Type of Casing Specifications ❑ Public ❑ Other 1 ❑ Delta Depth of Grout Seat ❑ Irrigation i Type of Grout Z 9 _�4pprox. Depth ❑ Eastern ' 5urtace Seal Installed by Repair Work done ❑ Type of Pump H•P, �S^ State Work Done�c�� ` Well Destruction ❑ Well Diameter Sealing Material (top 50') _ Depth Filler Materiel(Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION D REPAIR/ADDITION-C] DESTRUCTION ❑ (No septic system permitted if public sewer is t Installation will serve: Residence I available within 200 feet.) _ Commercial_ Other *, Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: I Water table depth SEPTIC TANK ❑ Type/Mfg _Capacity � No. Compartments PKG. TREATMENT PLT. D Method of Disposal p Distance to nearest: Well§ Foundation Property Line LEACHING LINE -allo.? 'Length of lines r-Tom" Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line it r � SEEPAGE PITS ❑ Depth t Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line r DISPOSAL PONDS i❑ k; _ 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 shah 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." The applican, st call for all rpuiow inspectiongW Complete drawing on reverse side. 'r Signed t l le: Date: FOR EPARTMENT USE ONLY t Application Accepted by D , �� __ Area Pit or Grout Inspection by Date Final Inspec ion by Date Additional Comments: �9-36210 -36D Stk 466-6781 ❑-LpManteca-823-7104 -T.racy-835-8385� Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 1 A FEE « AMOUNT DUE AMOUNT REMITTED CASH INFO � CK RECEIVED 8Y DATE pERM1T"NO.- +EH 1241REV.10!831 "�'� �111L q9 ��!_sy• L`_ EH 14-4-26 Jllf