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w APPLICATION FOR PERMIT i SAN JOAQUIN LOCAL HEALTH DISTRICT 45-3 1601 E. HAZEL T ON AVE., STOCKTON, CA No[�D Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 'AQ Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein desc eappl�anon 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 City Lot Size PM I x Owner's Name I U U106 Address Z iQ ` IZ_6r—q_ lPhone Contractor lj Address Lwicense Nozxol ( Phone X I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION El SYSTEM REPAIR ❑ _ OTHER ElDISTANCE 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 Ll Tracy Type of Casing Specifications { M Public f7 Other L Delta : Depth of Grout Seal 4 - 1 I Irrigation i1iA i Type of Grout pprox. Depth I I Eastern Surface Seal Installed by.---�.___ Repair Work Done Ll Type of Pump H,P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50'-) f Depth Filler Material (Below 50') =-y TYPE OF SEPTIC WORK: NEW INSTALLATION ['I REPAIR/ADDITION I I DESTRUCTION Y i (No septic system permitted it public sewer is . available within 200 feet.) installation will serve: Residence_ Commercial i Other - # Number of living units: ,11 Number of bedrooms ; Character of soil to a depth IE f 3 feet: Water table depth SEPTIC TANK ❑ -Type/Mfg CapacitY t _ '` ° No. Compartments PKG. TREATMENT PLT. ❑ f� Method of Disposal E ` Distance to nearest: Well Foundation {Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Nstance to nearest: Well Foundation Property Line SEEPAGE PITS i l Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 6 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 Sa'h 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 mariner 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 call or II rieJ.quired ins ction . Comple drawing on reverse side. Signed X Title: 1J/� 3 �-- Date: I� F DEPARTMENT USE ONLY Application Accepted by Date i Area Pit or Grout Inspection by �I. Date Final Inspection by z— Date d/ Additional Comments: ---------------------- ❑ Stk 466-6781 ❑ Lodil 1369-3621 11 Manteca 823 7104 El Tracy 835-6385 Applicant- Return all copies to.. Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ` I . I FEE AMOUNT E AMOUNT REMITTED INFO CK RECEIVED BY DATE PERMIT-NO. p . EH 13-24 IREV.I?H 51 EH 14.26 dl� .? !� r