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APPLICATION.FOR PERMIT 'r N' qwSAN JOAQUIN LOCAL HEALTH DISTRICT 1601�E. HAZELTON_AVE., STOCKTON, CA ,p1 Telephone {209) 466-6781 l PERMIT EXPIRES 1 YEAR FROM DATE ISSUED , .;r` (Complete in Triplicate) Application is hereby made to the"San Joaquin Local Health District fora 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. I 85"3 :k, ° °yg x 3s6 PM Job Address I� f City L. Size vJ�� Owner's Name Ca�' � �Add ss -2;3-5'3 E. Am #77—- Phone � . -1_S � b .�Prtrne._3Z3o i Contractor. I�u�11, Address Licensg�flo. TYPE OF WELL/PUMP: I1NEW WELL < WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ CSYSTEM REPAIR ❑ OTHER I] + DISTANCE TO NEAREST: SEPTIC TANK /00 SEWER LINES DISPOSAL FLD. 100 PROP. LINE FOUNDATION 10 AGRICULTURE WELL _—e— OTHER WELL / PITS/SUMPS 1�Q r. INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1' ❑ Industrial WOpen Bottom ❑ Manteca Dia. of Well Excavation f 1_�� n Dia. of Well Casing omestic/Private 0 Gravel Pack- C1 Tracy Type of Casing �' Specifications /014 4 C3 Public .. D Other ❑ Delta Depth of Grout Seal 0 Type of Grout Ll Irrigation pprox. Depth ID Eastern Surface Seal Installed by j Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well biameter Sealing Material (top 50') t f Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is I! available within 200 feet.) Installation will serve: Residence. Commercial_ Other Number of living units: Number of bedrooms 1 Character of soil to a depth of 3 feet: Water table idepth SEPTIC TANK - [I Type/Mfg Capacity No. Compartments , PKG.TREATMENT PLT. D �� Method of Disposal ., Distance to nearest: Well Foundation Property Line LEA CHINGyLINE ❑ No. & Length of Eines Total length/size t FILTER BED ❑ I�stance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ b'epth Size Number SUMPS ❑ Distance to nearest:" Well Foundation" Property Line t t DISPOSAL PONDS I] I; . 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.y"= t Home owner or.licensed agent's signature certifies.the•following-""I-certify that imtlie 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 applicant rnust-QallAor all r quired in ctio. fete drawing on reverse side. I7 r Signed �rr Title: �"/^�,�'-" Date: � �h FOR DEPARTMENT USE ONLY r Application Accepted by 'Date Area ' r; I � N Data Final Inspection by Pit or rout ins ction by 1 Date Additional Comments: I!' ❑Tracy 835 63B5 vStk-`"4W6781—--.:❑"L`odf- .369-3621 '—❑-Manteca'823 7104 ❑ Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazehon Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH 4 RECEIVED BY DATE PERMITO. N INFO. Al + EH 13-24 Mr=v.1/8 5) r ~(/ EH 14.29 �� -