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APPLICATION FOR PERMIT ` C A SAN .lOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) Application is heteby 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address O 3 N ACr' city S i�aC J 1'1 J"� oc? j �,/ Lot �s� k_� pM Owner's Name lqGl re- t�(�AtC-�®E, Address o —l 2/T Phone C i Contractor S 7 Address 20 '3 N r � } Dense No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION Cl SYSTEM REPAIR ❑ OTHER ❑ } 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 ❑ Manteca Dia- of Well Excavation Dia. of Well Casing ` ❑ Domestic/Private ❑ Gravel Pack CT Tracy Type of Casing Specifications r'l Public ❑ Other R Delta Depth of Grout_Seal Type of Grout I I Irrigation �.-Rpprox. Depth I I Eastern Surface Seal Installed by T Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ( I REPAIR/ADDITION-I,I-_DESTRUCTION (No septic system permitted if public sewer is savailable within 200 teet.I Installation will serve: Residence_ Commercial w Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments i PKG. TREATMENT PLT. ElDistance of Disposal EEEI Distance to nearest; Well Foundation Property Line 3 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size - Number SUMPS El 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 rules and regulations of the San Joaquin Local Health District. 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 for all required inspections. Complete drawing on reverse side. -� p \/ Signed X '09pA'Y C. I 41 C Title: 0(-/A/ J� Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Data Final Inspection by at Additional Comments: rt i ❑ Stk 466-6781 OLcd 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 . Applicant - Return all copies to: Environmental Health Permitl5ervices'1601 E. Hazelton Ave., P.O. Bd)i 2009, Stk., CA 95201 -> F r 1 FEE AMOUNT DUE AMOUNT REMITTED C INFO SH RECEIVER BY DATE PERMIT NO. -EH -24/REV,t i n 51 14 r,� �-•!t �}�/I --�77f/(�'(�v� �/(�/V']J H EH 14-28