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.^_ _APPLI.CAT-ION-F4R--PERAiti 1N_JOAaUIN LOCAL HEALTH DIS RICT 1601 E. HIAZEI.iON AVE.,,STOCKTON, CA ry�� j Telephone(209) 466-6781 Q �. 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 theSanJoaquin Local Health District. Job Address / City Lot Size 1A90 PM } - r f Q `� " Owner's Name '`� v i - Address S Phone k Contractor Address License No. Phone TYPE OF WELL/PUMP: D NEW WELL 11 WELL REPLACEMENT El DESTRUCTION 1-1 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS f 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 ❑ Other ❑ Delta Deo hF of Grout Seal Type of Grout ❑ Irrigation �pprox. Depth ❑ Eastern 5urfacce Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 j # TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑, DESTRUCTION,>QNo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms r Character of soil to a depth of 3 feet: I Water table depth SEPTIC TANK Type/Mfg Capacity No. Compartments _ ! f r I Method of Disposal PKG. TREATMENT PLT. ❑ t Distance to nearest:, 11Uell" oundation Property Line I LEACHING LINE ❑ No. & Length of lines ( j Total lengthlsize FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number k ` r SUMPS ❑ Distance to nearest: Well Foundation Property Line i DISPOSAL PONDS ❑ I r 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." 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 Cal" ia." The applicant t call for all requir inspecti Com ete drawing on reverse side.r N Signed X Title: :5-a Date: FOR DEPARTMENT USE ONLY Application Accepted by Date01 — Area Pit or Grout Inspection by Data Final'Inspection by Date Additional Comments: r < ❑ Stk 466-6781 ❑ L i 3621 ❑ antaca 823-7 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 �. INFO AMOUNT,DUt AMOUNT REMITTED C RECEIVED BY DATE PERMIT NO. FH 13 5 Ci�O 3 •� — 7 —91<0 EH 1426 -