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.>:049 " APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 r 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 the San Joaquin Local Health District. Sly city Lot Size PM Job Address Address hone Owner's Name .63 Contractor ILI e4 n �) n Address / ' License No.tsZ44 --Phone` TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ F PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER 11 ISTANCE TO NEAREST: SEPTIC TANKD o ; SEWER LINES DISPOSAL FLD. POOP. LINE I FOUNDATION J-44— AGRICULTURE WELL OTHER WELL PITS/SUMPS f � INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Ll Industrial Open Bottom ❑ Manteca Dia. of Well Excavation �r�- Dia. of Well Casing ., Domestic/Private vx ED Gravel Pack 1:1 Tracy Type of Casing PG j Specifications ll Public , Cl Other rF Delta Depth of Grout Seal T pe of. rput I . -Q(�_.Approx,YDepth �l I Easterrn• *_Surface Seal Installed by �" - I ! Irrigation - ''" _�. — 'State Work Done Repair Work Done ❑,_Type of Pum H-P• Well Destruction M. Well Diameter Sealing Material (top 501 t Depth Filler-Material (Below 50.1 TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION { I DESTRUCTION I 1 INo septic system permitted if public sewer is \fi available within 200 feet.) Installation will serve:",Residence— Commercial_ Other Nu bei of living units:)- Number of bedrooms Character of soil to a depth of 3'feet: Water table depth _ SEPTIC TANK LJ .:Type/Iutfg Capacity No. Compartments ' •.� Methcd.of Disposal PKG_TREATMENT PLT. ❑ Distance to-nearest: Well Foundation Property Line i a LEACHING LINE ❑ No. & Length of lines -� �` Total length/size FINER BED ❑ " Distance to nearest: Well "l Foundation Property Line,.� SEEPAGE PITS 11 ' Depth Size »s4 Numbers SUMPS Cl Distance to.nearest:" Well Foundation Property Line k 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. a Home owner ar 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 California." The'applicant must all for all required inspections. Complete drawing on reverse-side. Signed X tle: — - Date: FOR DEPARTMENT USE ONLY # t /'� Application Accepted by Date 4, rea VPit o Grou Inspection by date Final Inspection by — Date . s Additional Comments: +--- . . _�..-❑ Stk,W66=6781^x"'"`-'O"L"o'�i 369-3621 ❑ Manteca 823-7104 CD Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E:Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i` FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO nJ� + EH 13-24 1REV.r i n 51 lO C , ~' EH 14-26 _