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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH`DISTRICT r .,.I * I 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED :3 (Complete in Triplicate) App 1c`ation is hele6y'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. j.862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address , Ciitty "r Lot Size PM Owner's Name + dress Phone Contractor Address }��T�-tom S� License No. 413 Ph,ne"l� -1365 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ - ,DESTRUCTION`[] Q �n PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom CI Manteca -Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private I-] GravelPack 71 Tracy Type of Casing Specifications C t-i Public ` Ot�1er D Delta Depth of Grout Seal Type of Grout 'y�`�U� I I Irrigation-VI r�S[Approx. Depth I I Eastern Surface Seal Installed by� t"1 Repair Work Done ❑ Type of Pump H.P. State Work Done 44)yE--�. ar. W�� &t-,5- Depth , Well Destruction ❑ Well Diameter Sealing Material (top 50') !ir� Depth Filler Material (Below 50') Li a( & f_-C� A,&56 TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) �. Installation will server Residence— Commercial— Other r I Number of living units: Number of bedrooms I Character of soil to a depth of 3 feet: Water table depth } SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. ❑ Method of Disposal t y Distance to nearest: Well Foundation Property Line II I LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 I rules and regulations of the San Joaquin Local Health Diltrict. 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 signature i 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 Ca rnia." The applican 5� at required inspections. Complete drawing on reverse side. ij Signed X Title: � r``-t Date: J �� i F R EPARTNIENT USE ONLY i Application Accepted by Date Area j Pit or Grout Inspection by Date Final Inspection br✓ Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 C] Manteca 823-7104 ❑ Tracy 83549385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 Jo a FEE � I I INFO AMOUNT DUE AMOUNT REMITTED CA H RECEIVED 6Y DATE PERMIT'NO. r.EH 13-24(REV. /Hr) 7'OV v J Vo (y !y, }] Cif EH 1406 � �d W r'�_�(� '�Q' 1q5 � ��