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mss' - all APPLICATION FOR PERMIT ✓ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA SEP Z� '9� Telephone (209) 466 6781 PERMIT EXPIRES 7 YEAR FROM DATE ISSUED �w+l�' 'ENTAL HEALTH (Complete in Triplicate) Fttuw,; J SERVICES 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 welUpump and the Rules and Regulations of the San Joaquin Local Health District. p q Job Address ( � �n City 166a_ Lot Size PM Owner's Name T r /UI�L(l�, . OAdp 7 dress _(3 !Q e � Ll�' C�Q([/ Phone Contractor Address ' S 60(,ense No. o79Q J3 Phone TYPE OF WELL/PUMP: -NEW-WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR © OTHER ❑ .,DISTANCE TO NEAREST: SEPTIC TANK IM"t SEWER LINES DISPOSAL FLO. 100'f' PROP. LINE FOUNDATION AGRICULTURE WELL _ OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom X Manteca Dia. of Well Excavation /�•" - Dia. of Well Casing DomestigPrivate Gravel Pack ❑ Tracy Type of Casing r� Specifications f M Public y n Other 171 Delta Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth I 1 Eastern Surface Seal Installed b f[LL1.t t Y Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50') ; Depth Filler Material (Below 50') _ TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTION i I (No septic system permitted if public sewer is available within 200 feet.) S Installation will serve: Residence_ Commercial_ Other S Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth .SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal a Distance to nearest: Well Foundation Property Line 4 I LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line i SEEPAGE PITS l I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL.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 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." Contractors 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 lawsof California." The applicant ust call for all requ' d inspecti ns. Complete rat on reverse side. Signed X �]L Date: O FOR DEPARTMENT USE ONLY Application Accepted by '1 Date Area 0 Pit or Grout Inspection 4DLod�i Date " Final Inspection by—4 Date r� Additional Comments: ❑ Stk 466-6787 621 ❑ Manteca 823-7104 0 Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED INFO CASH RECEIVED BY DATE PERMIT*NO. r.EH 13-21IREv.t/k51l ' EH 14-20 b v� ,-b - ��rsr-tico