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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ' 1601 E. HAZETON AVE., STOCKTON, CA r 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 described. This application is made in compliance with San.Joaquin County-Or-diffN ce No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. � ' 800 CORRAL. Hd`�°w IR C Job Address City y Lot Size PM Owner's Name Nke' Cflc,Rek1 Address P'W- Phone 83S e;La ` v 4 a Contractor 1 1 M `-A(kc-%t E Address Ste .S UE License No. 1 C& Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ `I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. ,PROP. LINE FO.UNDATIO_N AGRICULTURE WELL_-_ QTHEfi WELL ��" PITSISUMP,S INTENDED USE^* TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS (� ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 3 ❑ Domestic/Private 0 Gravel Pack ' ❑ Tracy .,Type of Casing ; Specifications l`I Public ❑ Other . "i-_F Delta•. Depth.of Grout Seal Type of Grout I I Irrigation --Approx. Depth I ).Eastern Surface Seal Installed by.` ' Repair Work Done ❑ Type of Pump -H.P: s ` �,State Work-Done Well Destruction. ❑ Well Diameter Sealing,Material (top 501) w T _ Depth Filler Material (Belo 5011 Y , t TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIRIADDITION PV DESTRUCTION_ I1 .1No_septic system permitted if public sewer is t / 'Nlavailable within 200 feet.) t Installation will serve: Residence'/ Commercial=Other a� i �r.... Number-of living units: 'Number of/bbedraams Character of soil to a depth of 3 feet: `f e�V Y ` W M Y r � Water table depth j SEPTIC TANK ❑ Type/Mfg Capacity -R No. Compartments E PKG. TREATMENT PLT. ❑ Method of Disposal I Distance to newest: well r Foundation Property Line LEACHING LINE F'*'No. & Length of lines #��7=0 ✓' f Total length/size FILTER BED ❑ Distance to nearest: i Well Foundations Property Line SEEPAGE PITSDepth $ , �� ZPX 10K. 2.' — Number �. _ I� �x `�ze SUMPS ❑ Distance to nearest, Well Foundation Property Line DISPOSAL PONDS-----❑ -. �.{ I hereby certify that I have pfepaied 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. "7 Home owner or licensed agent's signature certifies the following s„I.certifythat 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 taws of California.” Contractor's hiring or sub-contracting signature certifies the following- )_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." t # The applicant must call for all required ins ctions. Complete drawing on reverse-side. Signed X Title: (�K-yfU�IL Date: FOWDEPARTMENT USE ONLY" - � __..,Date. . Aj Area ' Application Accepted by -y _ _ I ti Pit'or Grout Inspection by Date Final Inspection by Date C - Additional Comments ❑ Stk f466-6781 odi 369-3621 ❑ Mant 823-7104 ❑ Tracy 835-6385" __-,,,,_Applicant,.:„,Retu,np�_all-copies to:.En%ironmental-Heaith.Permit/Services-1601-E.-Haze!ton_Ava.,-P_.O.-Box-2009,:.Stk.ti-CA-95201— - I INFO AMOUNT DUE ` AMOUNTiREMITTED CK 7 ;.RECEIVED BY D�AyTE/y� PERMIT'NO.FEE y r EH 13-24(REV. /n5) EH 14-26 v � �