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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) 2-,59— &C,,o -Q 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. 1852 for well/pump and the Rules and Regulations of the San Joaquin Local Health District.:r,E,.,: �. , Job Address _rib X i e 4- '_:r26n' :.µ.ft[' City 1 d✓� Lot Size PM Owner's Name Address Phone Contractor r V0 on,12-r Address o 60-x3Pldt5-kicense No.,16_36 T%Phone TYPE OF WELL/PUMP: I NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Ule S , PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE `a �r.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 Dia. of Well Casing ❑ Domestic/Private 12 Gravel Pack ❑ Tracy Type of Casing Specifications t � ❑ Public ❑ Other I ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation !___�Approx Depth ❑ Eastern Surface Seal Installed by f Repair Work Done ❑ Type,of Pump 0H.P. State Work Done Well Destruction Well Diameter / Sealing Material Itop 501 Depth 35 !1�Q Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.} Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet! Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ I Method of Disposal -�" Distance"o nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size i FILTER BED ❑ Distance It, nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number i SUMPS ❑ Distanceii16 nearest: Well `" Foundation Property Line xF 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. I 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,1 shall employ persons subject to workman's compensa- tion laws of California." The applican t cal r all required(inspections. Complete drawing on reverse side. t Signed Title: - Date. FOR DEPARTMENT USE ONLY I' Application Accepted by t T ` Date y �•--� ^� Area Pit or Grout Inspection by r• V k Date ' a- Final InspectionbyDate ,5 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 > antece 823-7104 ❑ Tracy" 835-6385 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 RECEIVED BY DATE PERMIT NO. INFO !�t'1 Q-K CA11� /� 7Ek 13-241REV.t/65l 3E0 0 35�- ! l �'�7 $+ �1 Cri EH 1428 111 JJ j/