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i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1.YEAR FROM DATE ISSUED s .q - . (Complete in Triplicate) ...�• �I Fi. ....r, •.i•s� 'Jf ..J. - it 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. �.y� Job Address j �`i ..R C. / /��u f�OX/J v ' City rLot Size. PM Owner's Nam Address 5 6e /�3 �-/� p �. Phone CJ 70 r Contractor Address I License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ t SYSTEM REPAIR ❑ OTHER ❑ s DISTANCE TO NEAREST: SEPTIC TANK i SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION •'± AGRICULTURE WELL OTHER WELL PITS/SUMPS t INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS } ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ PublicDomestic/Private 1:1 Gravel Pack ' O Tracy,.^ Type of Casing Specifications 11 Public ❑ Other r ❑ Delta `-�,Depth of Grout Seal T I-] Irrigation ---Approx. Depth LJ Eastern Surface Seal Installed by Type of Grout Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') j Depth,p Filler Material /Below 5011 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRlADDITION ❑ DES TION {No septic system permitted if public'sew vailable within 200 feet.) Installation will serve: Residence_ Commercial_ Other. p Rif$!G N 5��o FI F Number of living units: Number of bedroomsi t Character of soil to a depth of 3 feet: A - Water table ept M SEPTIC TANK ElType/Mf Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Di sposal j Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest:. -= Well Foundation -� Property Line SEEPAGE PITS ❑ Depth Size f -w Number I SUMPS ❑ Distance to nearest: Well ? �` # ` 1 ❑ Foundation { Property Line DISPOSAL PONDS 1 I hereby certify that I have prepared this application and that the work will lie done'in accordance with San Joaquin county ordinances, state laws, and i rules and regulations of the San Joaquin Local Health District. + r F 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 sign'atu're 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 must call for all re fired inspections. Complete drawing on reverse side. Signed X y -� _ Title: Date: FOR DEPARTMENT USE ONLY 4 a Application Accepted by Hate Area Pit or Grout Inspection by Date Final Inspec on by to „^itional Comments; tk 466-6781 J� odi " -3&21 ❑ Mante 823-7104 D Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O..Box 2009, Stk., CA 95201,,: " 0 Glut PC - G C r L ( fj4 C u c[ __ /� V ^rFEE_-„'AMOUNT DUE�� -p-AMOUN7K�I�ED— ""C '”—RECEIVEp ey— �"" 'NO.- INFO �SU DATE '�pERM + EH 13-24 1REV.I/n 5) //rye r — EH 14-28 V I' �U...-