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APPLICATION,FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.-HAZEI_TON AVE., STOCKTON, CA Telephone [209) 466-6781 E t .,, :,,.:. .. PERMIT EXPIRES'1 YEAR FROM.DATE ISSUED . wL(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. a r r v z t Job Address �� a � -/ T City A Lot Size PM Owner's Name-5�ll�r STD�� d Address �� o��l� Phone 70 211-1417— U All vc5tSA L p Contractor's Name O 1a '� �i1 License No.. Phone I✓ r `?Ji TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ~` — DISPOSAL FLO. PROP. LINE - FOUNDATION -�=- " AGRICULTURE-WELL-=.--. r —OTHER WELL, -PITS/SUMPS -. i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Xl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications t ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ,,99 ❑ Irrigation ----Approx. Depth ❑ Eastern Surface Seal Installed by 0 Repair Work Done X, Type of Pump isU'Q H.P. C State Work Don E Well Destruction ❑ Well Diameter I Sealing Material Stop 501 Q Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION, ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is I available within 200 feet.) Installation will serve: Residence—E Commercial_ Other ? Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water tattle depth,' SEPTIC TANK ❑. Type/Mfg Capacity No. CompartrrEents G PKG, TREATMENT PLT. ❑ Method of Disposal. Distance to nearest: Well, Foundation Property Line LEACHING LINE © No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well FoundafionA Property Line SEEPAGE PITS ❑ Depth Size Number :SUMPS,. ? OsDistance-to nearest:r- iWeIE _ Foundations Property Line - - - ;== DISPOSAL PONDS 1:1A x � 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 su manner.as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following:' ertify that in the rformance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California l The applicant mus c fo af!r uired in s. Com �+ r Signed y Title: � S w Date: FOR DEPARTMENT USE ONLY Application Accepted by ' DIf ate Area - i ► s _ Pit or Grout Inspection Date Final Inspection by Data Additional Comments: ❑ Stk ;466.6781.: ; LJ-Lodi^38943621 Q Manteca 823-7104 - -B:Tracy-835-&M Applicant=Return all copie.s•to:.'Erly ronmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,Stk., CA 95201 F}ae,:e.z .1 ;til. ,£ E ..� - - -- • -- -. _..,.I - F. ...- .. .- .._ i - - FEE CA INFO AMOUNT DUE . AMOUNT REMITTED C SH RECEIVED BY DATE PERMlT''NO. +'EH1324(REV.101831 EH 14-26 . . . .