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I -- I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT T _ 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466.6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 7A (Complete in Triplicate) S 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 cp,40d-ol w City C�C/„u Lot Size_do *Gz£ PM t Owner's Name Address,. phone Contractor's Name License No. p TYPE OF WELL/PUMP: Phone NEW.WE L ❑ WELL REPLACEMENT ❑ <4-DESTRUCTION ❑ r x" PUMP INSTALLATION ❑ - / SYSTEM REPAIR"lam , OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANO # SEWER LINES DISPOS_ AL'`Fl i7 PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS I INTENDED USE TYPE OF WELL, PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation . 11Domestic/•Private -0 Gravel Pack-- -D Tracy"' -�- Type of Casing"` Dia. of Well Casing ❑ PublicSpecifications ❑ Other a 11 Delta _ Depth of Grout Seal . Q Irrigation Type of Grout ---Approx. Depth ❑ Eastern Surface Seal Installed by N Repair ork Done ❑ Type of Pump. H.P. State Work Done D Well estruction ❑ Well Diameter Sealing Material (top 501) Depth ,-filler Material IBelow 50'1 ^ TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION D DESTRUCTION ❑ (No septic system permitted if'public sewer is 1 available within 200 feet.) installation_will serve:-Residence_ Commercial Other Numberrof_living-units:_ tiumber of'bedrooms Character Fof soil to a depth of 3 feet: Water table depth l SEPTIC TANK ❑ Type/Mfg PKG. TREATMENT PLT. ❑ Ca aci P tY No. Compartments �• IrMethod of Disposal I Distance nearest: Well Foundation- ,eld Property Line Ld I LEACHING LINE,,- ❑ No. &,Length of lines O Total length/size i FILTER BED. i' - ' ❑ Distance to nearest: Well Foundation E + 1 Property Line k SEEPAGE PITSAg- Depth.' 'Size z Ni__ _ ".,r I Number SUMPS ❑ Distance to nearest: Well Foundation DISPOSAL PONDS 1`7 Property Line ; 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, f Home owner or licensed agent's signature certifies the followin f i g: "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 California." t The applicant St- 11. -al uired specti s. Complete drawing on reverse side. F. ; Signed Title: Date: 12 FOR DEPA TMENT USE ONLY Application Accepted by1&5 � Date-y—(7 --Z rffr% Area 7 4s Pit or Grout Inspection by f Date Final Inspection byDate S- A�Oitional Comments: i ' Stk 466-6781 EILodi 369-3621 C3 Manteca 823-7104 11 Tracy 835-6385 licant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE CK# INFO AMOUNT REMITTED CASH RECEIVED BY D;FS S PERMIT NO. +EH 13-24(REV.10183) ` q O �+��7 EH 1426 -- �� -1 _