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r r+ L, APPLICATION FOR PERMIT 1II jff SAN JOAQUIN LOCAL HEALTH DISTRICT,;' 1601 E. HAZEL T ON AVE., STOCKTON, CA l � 4 f�n1 t 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 and Regulations of the San Joaquin Local Health District. Job Address City_!�Q� ! Lot Size PM Owner's Name Cl S ��-� Address 1�5 � ��ctr>s �1 Phone �3&y".z Contractor d-.S[7rt S Address Y7� -_�S_t"-ro eT 10r' License No.JS7�C�D��/ Phone_7`� � �2 2 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT DESTRUCTION ❑ " PUMP INSTALLATION L SYSTEM REPAIR ❑ . OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK f�'�' SEWER LINES DISPOSAL FLD. PROP. LINEa" � FOUNDATION-r- ��• AGRICULTURE WELL __=OTHER WELL ,0_2: � PITS/SUMPS w INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS LI Industrial Open Bottom ❑ Manteca Dia. of Well Excavation ` ' Dia. of Well Casing VDomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing=ST<<,L_ Specifications l`l Public l7 Other 17� Delta Depth of Grout Seal ? - Type of Grout # I f Irrirlanon 19C' Approx. Depth , I 1 Eastom Surface Sual Installed by Repair Work Done ❑ Type of Pump H.f P. =- State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material IBelow 501 . 'I TYPE OF SEPTIC WORK: NEW INSTALLATION ("I REPAIR/ADDITION I I DESTRUCTION 1.1 (No septic system permitted if public sewer is available within 200-feet:) u Installation will serve: Residence_ Commercial Other V Number of living units: _ Number of bedrooms Character of soil to a depth of 3 feet: _ _ Water table depth V SEPTIC TANK ❑ Type/Mfg Capacity-- No. Compartments PKG- TREATMENT P[T. C_l Method of Disposal Distance to nearest: Well Foundation Property Line r LEACHING LINE I� No. & Length of lines . T Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: Well Foundation. Property Line DISPOSAL PONDS L] x j 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. r 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 f employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring er sub-contracting signature l 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." I The applicant must call for all repo"red inspections. Complete drawing on re}ver a side, L Signed X /Jst .._.. --Kt _ Title: '"'^ Date: 7 1 _ FOR DEPARTMENT USE ONLY Application Accepted by Date -4 Area [� Pit or Grout Inspection by Date /Final Inspection by Date Additional Comments: d LiL �T�YY) ✓=!Je 0 s 171Stk 466-6781 ❑ odi 369-3621 ❑ Manteca ti 823 7104 E Tra y 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE CK !� 'INfD MOUNT DUE AMOUNT REMITTED CASH RECEIVED 13Y DATE PERMIT NQ. +.EH 1324 IREV.I/As 1 /''y �,y`� EH 14.79 �..J 1 �.Vv y '`-wSr-mow