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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRACT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES I'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 Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. ,�p Job Address 4 City Lot Size Owner's Name Address _32-70 C_7, Phone 3O?- Contract r ti + W Address A01) BOX wo ( 4nk License No.� Phone TYPE OF WELL/PUMP: NEW WELL.❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ' ❑ industrial C] Open Bottom 171 Manteca Dia. of Well Excavation Dia of Well Casing ❑ Domestic/Private ❑ Gravel Pack.-`!-4'. -❑ Tracy, �;Y.� Type of Casing Specifications M Public i] Other ❑ Delta Depth of Grout Seal Type of Grout __ r +i I Irrigation —.Approx. Depth a t I Eastern � Surface Seal Installed by - Repair Work Done ❑ Type of Pump H,P. State Work Done Well Destruction ❑ Weil Diameter Sealing Material Itop 501 1� Depth Filler Material {Below 50') "6 = w, — 7yfP OF SEPTIC WORK:- NEW INSTALLATION REPAIR/ADDITION i I DESTRUCTION (No septic system permitted if public sewer is * 1 �••V1 ! _ �. f' available within 200 feet.) O r,; lnstallaiion_will.serve f, Re Bence�'Cbmrnerciai Other � Number-of IN66 units CA Number-° b drooms a_✓6� =f " fi ` ' Water table depth Character of soil to a depth of 3 feet:.. � SEPTIC TANK Type/Mfg- Capacity p No. Compartments PKG. TREATMENT PLT. ❑ 4_t _ -- < Method of Disi,osal Distance to nearest: Well So Foundations Property Line ( f LEACHING LINE �L< No. & Length-of'llnes 3 ' go` Total length/size 1t FILTER BED ❑: Dista?1ce to nearest: Well Foundation Property Line SEEPAGE PITS Depth c2s, Size Number „ SUMPS 'hl Distance to nearest: Well/00 Foundation Z— Property Line ; r DISPOSAL PONDS ❑ �r - ` � 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 i 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 applican ust call f I req fired inspections. Complete drawing on reverse-sicia. r Signed X Ti.: Date: 0 FOR DEPARTMENT USE ONLY �i J pplication Accepted by Date - `=' Area-k3 3 Q01 or Grout Inspection by Date l S �Q Final Inspection by _ Date v i Additional Comments: - ❑ Stk 466-6781 ❑ Lodi 369-3621 0 Manteca 823-7104 Q Tracy 835-fi385\ ..�� Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O'Box 2009, Stk.f CA 95201 FEE AMOUNT DUE AMOUNT REMITTEDCASH RECEIVED BY DATE- sr PERMIT�NO. INFO - r.Eli 13-241REV.i/nsl EH 14-2a - kv