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APPLICATION FOR PERMIT .� SAN JOAQUIN LOCAL HEALTH DISTRICT }' 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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 d i . 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. 1 / Job Address /�S l �(r. I ex"L4/Cr City Lot Size PM l Owner's Name , �• Address Phone Agdrc.11,7 Contractor Address License No. Phone TYPE OF WELL/PUM ,. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIONi❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER',O 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 1 ❑ Manteca Dia. of Wall Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack r.. ❑ Tracy Type of Casing Specifications I') Public Il Other ' n Delta Depth of Grout Seal Type of Grout I I Irrigation —Approx. Depth I 1 Eastern Surface Seal Installed by. _ Repair Work Done ❑ - Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter' K Sealing Material Itop 501 �\ Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ 'Commercial_ Other Number of living units: _ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ElType/Mfg Capacity No. Compartments PKG.�TREATMENT.PLT!❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size 1, FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS V,�l.-Dnpth ___,Size Number - SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereW_oenify that I have prepared this application and that the work will be done in accordance with San Joaquin coty ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "1 cenify 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 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."I The applicant ryust call for all required inspections. Complete drawing on re rse side. Signed X Title: r�--0!3!•u,}�, Date: 74 ^. FOR DEPARTMENT USE ONLY ` Date Application Accepted by r1--� / Area• Pit or Grout Inspection by ��' Da[a Final Inspection by Date �� '- Additional Comments: - ❑ Stk 466-6781 ❑ Tracy 835-6385 Applicant - Return all copies to: EnvironArantal a Ith audit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 85201 INFO AMOUNT DUE AMOUNT REMITTED 11 C H RECEIVED BY DATE-: fsP,ERMIT'NO. . EM 1324 IREV.rix-.l - ��:� 7 �� ^113{ //��T�/ r�y'�,f ✓'�