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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON-AVE., STOCKTON, CA Telephone (209) 466-6781 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 pnd Regulations of�he San Joaquin Local Health District, 5g4y3qq/?(aq5- 4;W' r Job Address p � � lam_ CityW A+of Size PM Owner's Name`�'y -Address + � - / Phone G r Contract6F+ -dress � License No.� p z�(- Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ � I PUft�P INSTALLATION ❑- SYSTEM REPAIR ❑ OTHER ❑ ' DISTANCE TO NEAREST:'SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA 'CONSTRUCTION SPECIFICATIONS ❑ Industrial { ❑ Open Bottom ❑ Manteca Dia. of Well Excavation s: Dia. of Well Casing A ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing F Specifications 1 l l Public Cl Other l l Delta Depth of Grout Seal f TYPe of Grout I I Irrigation ° r —.-Approx. Depth I. I Eastern Surface Seal Installed by 4 Repair Work Done 0 Type of Pump H.P. 'State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 f P Depth Filler Material (Below'50') - TYPE OF SEPTIC WORK: NEW INSTALLATION 5< REPAIR/ADDITION I I DESTRUCTION i I (No-septic system permitted if public sewer is , n f available within 200 feet.) r u= Installation.will serve: Residence Commercial- r Other Number of living units: Ji' Number of be .ms C / `/ _j ~"r`�� ZCharacter of soil to a depth of 3 feet: , �� - f� Water t b e.d pth SEPTIC TANK �a� Type/Mfg Capacity� / �, Com?pa tments CK x r ' PKG. TREATMENT PUT. r e 4 ' Meth f'of Disposal z Distance to nearest: We11 ..`_` Foundation!� Property Line ' `� , LEACHING LINE No- & Length of'hnes Total length/size A FILTER BED ❑ Distance to nearest: Well 100-F6undation 10. � '+Property Line . .. O z ,ice ./ - ,/_2 z _ SEEPAGE PITS / Depth Size ; { SUMPS f L-1 Distance to nearest: Weil /ti +� Foundation Property Line DISPOSAL PONDS/ ❑ el .K hereby certify that I have prepared this application and that the work will be done in-accordance with San Joaquin:eounty 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, 1 shall not employ any person in such manner as to become subject to workman's compensation-law-s of California."Contractor's hiring or subcontracting 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 compensaIND - tion laws of California." II ; The applicant / st call for eq red inspections. Complete drawing on reverse 'de. _ (> Signed X Title: ' �• �; Date: 3.�! �1U ��JJJJ �I FOR DEPARTMENT USE ONLY Ap ication'Accepted by�rn �` Date�11— I— Area y r Grout Inspection by Date (�, -ry Final Inspection V Additional Comments: ❑ Stk 466-6781 . ❑ Lodii 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-63$5 Applicant - Return all copies.to: Environmental Health Permit/Services 1601 E. Hazelton-Ave.,'P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK 1RECEIVED SY `. DATE PERMIT NO. INFO +��(L CASH ,.EH13-24IRE' .i/xsl 1 1Fay . \\\jqqo qO-,��jf�](Q EH 14-28 ll