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i APPLICATION-FOR PERMIT tom.. SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA _ Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE.ISSUED p {Complete in jriplicate) is 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 3 fir.-^: F ty .. 4„j t 5 1t c jl Jab Address �! 9 P1.f7'!1! y ��ltA �� Cit "' Lot Size q /� Owner's NameNt � Address hone f R A Contracto Address License No,32 Phone TYPE OF WELL/PUMP: NEW WELL ElWELL REPLACEMENT ❑ DESTRUCTION LJ k PUMP INSTALLATION ❑ " SYSTEM REPAIR ❑. OTHER ❑ T -.. „ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. NE # FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS II; INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well.CasiADQ �Q Domestic/Private ❑ Gravel Pack Tracy Type of Casingr Specifications ElEl } t Type of Grout t ❑ Public 171 Other ❑ Delta Depth of Grout Seal I -V ❑ Irrigation ---Approx. Depth Il Eastern. Surface Seal Installed by41 , Repair Work Done ❑ Type of Pump H.P. State Work Done Sealing Material (top 50'15 1 - Wel! Destruction LJ Well Diameter '��* � Depth ' j Filler Material (Bel ) TYPE OF SEPTIC WORK: NEW INSTALLATION F EPAIR/ DITION 1K DESTRUCTION ❑ (No septic system permitted if public';sewer is a 'labia within 200 f.et.) ,I, Y._ •F Installation will serve: Residence_ Commercial, . Other r Number of living units: —t9- Number of bedrooms ' Character of soil to a depth':of 3 feet: Water table depth rCapaci No. Compartments I SEPTIC TANK L1 'Type/Mfg Capacity— PKG. TREATMENT PLT. ❑ `; +. ` Method of Disposal �. ,:Distance to nearest: Well I" Foundation Property Line � r g� 4 LEACHING LINE No: & Length of lines f Total length/size-4- FILTER BED ❑ ..Distance to nearest: We'll" N Foundation Property Line \n SEEPAGE PITS GYDepth Size �` ` Number l SUMPS El ;Distance-to nearest: Well-'5F undation �-P-roperty-Line—i 1 DISPOSAL PONDS ❑ v . 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. `x 1 *tom 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, l shall not employ any person in such manner as to become subject to workman's compensation laws of California.'.Contractors hiring or sub contracting signature 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." 4 y' The applicant mu call for all requir d inspections. Complete drawing on reverse side. ?, �7t r �_ Signed .r2-: Title: Date: l2,.,_ FOR DEPARTMENT USE ONLY - it . _2 Application Accepted by A Date 7 Area- - Date �Z� Final Inspection by Date v Pit or Grout Inspection by j.� ,+ Additional Comments: ❑,Stk 466=6781--�C-I-L•odi•--369-3621�—EI—Manteca"823-7104"Ei Ttacy"•"8356385 {� + 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 CASK RECEIVED BY DATE PERMII�NO.' INFO ��Z�'�rto t�sb— s11� t t EH 13 REV.1/H 61 �� . EH 14.26 .