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APPLICATION FOR PERMIT i SAN JOAQUIN LOCAL HEALTH DISTRICT i 1601 E. H_ AZE;TON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 'I YEAR FROM DATE-ISSUED q-& PERMIT (Complete in Triplicate) ._1u�r; 2�D �al 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 i 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 He I h District. / `'a f .; U � ,;ql �..., Xg —VJob Address` City ��- Lot Size A ` PM '�r + ,ny� t Owner's Name — Address oZ l Y�� 1� (�ai l 'I 1" (1'(. Phone u _ %' 1/7 Contractor's Name License No. —'Phone i I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION'❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ / I OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK' SEWER LINES DISPOSAL FLD. PROP. LINE` FOUNDATIONS % AGRICULTURE WELL OTHER WELL PITS/SUMPS i INTENDED USE TYPE OF WELL IPROBLEM AREA CONSTRUCTION SPECIFICATIONS =` ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation pia. of Well Casing = ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy r Type of CasingSpecifications ''1 ❑ Public ❑ Other 1-1Delta J, Depth of Grout Seal !" Type of Grout F ❑'Irrigation _ —Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done ' Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth IF Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIWADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is t available within 200 feet.I Installation will serve: Residence)L Commercial— Other �s Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: --r"r f �` Water table-depth 0 SEPTIC TANK ❑ Type/Mfg PPI- rzL(r— _ Capacity ;2 ° No. Compartments PKG. TREATMENT PLT. ❑ I Method of Dispol Q Distance to nearest: Welles Foundation . A9 r` Property Line_ LEACHING LINE >e—.No. & Length of lines^ -7 r Total length/size FILTER BED ❑ Distance to nearest:" Well Foundation �d � Property Line SEEPAGE PITS ❑ Depth Size Number _ __ti I SUMPS ❑" Distance to nearest: Well —Foundation _.Property Line i 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."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 ust call for all required inspection Complete drawing on re arse aid . Signed X Title:. Date: �—7 FOR DEP RTMEN SE ONLY C �/ �} Application Accepted by --7 Date r r� r ,e/ Area Pi or�rgout Inspection atce p ma ate Additional Comma 1 e1�Gl*� (W.f I11C 60VCY�(� hE4^1 �t, a f-� /�eYyy�i�— O C 1 Stk 46646781 antecs 823-7104 ❑ Tracy 835-6385 V e.V4t -f#f fir,K �c i p Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 915201 f+7^� kC14, 0)( jfkrll^ r'f e jM+ly�e �6f/��4rr7UhdGv:j°Lc 7�'e G 10 SOF ytsGk Oh n). a dY �d Q�r0)'+.,ef, frb�k INFO AMOUNT DUE AMOUNT REMITTED A5 RECEIVED BY i EH13241REV.101831 ^�7 gY Z�5 EH 1428 ff rF/