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,APPLICATION FOR PERMIT - ,,= v �. SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE.,:STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1,YEAR FROM DATE ISSUED t+ . (complete in.Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work hereindescribed. 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`` k` 40 Job AddressCity . Lot Size C� PM Owner's Name r-- -' 105Address ! A L V Phone Contractor /A a V� �� -`Address - F F _%dCALicense No. 7 6Sl DE7Phone "41 TYPE OF WELL/PUMP: NE1NcWEL•L 0')�* WELL REPLACEMENT-ED DESTRUCTION ❑ � 1 X'` �l`PUMP INST,& TION El— —SYSTEM-REPAIR-❑ " OTHER M` ; DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE i FOUNDATION. RI, AGRICULTURE WELL OTHER WELL PITS/SUMPS �3 INTENDED USE TYPE OF WELL—j PRQBLEM AREA—CONSTRUCTION SPECIFICATIONS ❑ Industrial ( ' Elit Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/.Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public �' � � t x, O Other ', —0 Delta Jam"' Depth of Grout Seal � ' Type of,Grout t ! . Ll Irrigation � �Approx. Depth- El Eastern- F--Sur#aca Seal-installed- Repair talled'by .� � Repair Work Done ❑ Type of Pump H.P. State Work Done s k Well Destructions ' ❑ Well Diameter Sealing Material Itop 50'1 f Depth /4 Filler Material (Below 501 f � TYPE OF SEPTIC WORK: NEW INSTALLATION 9 REPAIR/ADDITION-❑, DESTRUCTION {] Wo septic system permitted if public sewer i i s'• '`.: 'available within 200 feet. t. Installation will serve: Residence_X Commercial— Other '1 - Number of living units: Number of bedrooms i ' ,�,° .0 ' Character of soil to a depth of;3 feet: 40L D ��.�,.-- :� Water table depth i SEPTIC TANK H Type/Mfg "�' Capacity- � No. Compartments , PKG. TREATMENT PLT. ❑ Method of Disposal, Distance to nearest: Ikell .,- Foundation-"} Property Line :r LEACHING LINE No. & Length of lines _ T I length/size FILTER BED O� Distance to nearest:„ -Well k Foundation Property Line s s 11 r,� �S ♦!s SEEPAGE PITS I]# Depth - size `-" } Num er + SUMPS Distance to nearest: - Well Foundation roperty Line DISPOSAL PONDS ❑I ' 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, a l rules and regulations of the;San.Joaquin.-Local-Health-District.. !- g 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 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." The applicant must call dfor�re ;d7tions-,Gomplete drawing on reverse side. [ i Signed X Title: t "bate: OR aEPARTMENT USE ONL i Application Accepted by Date / 41—Area ' r lfin 11 Pit or Grout Inspection by Date Final Inspection by date d Additional Comments: 5 I ❑ Stk 466-6781 odi 3697.3621 ❑ Manteca 623-7104 0 Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Avp. P.O. Box 2009, Stk., CA 95201 r. �. FEE AMOUNT DUE AMOUNT REMITTEE$ CK E ' r INFO s—CASH_ ry R@�EIVED BY W DATE PERMI7_NO, , + EH13-24(REV.t I"5) EH 14-28 � ! l/✓ 1