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t APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.-HAZEL T ON AVE., STOCKTON, CA ` Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 4 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. 7, OT.T:,,.r ' Job Address J f&7 .- t� ��``� City Lot Size /0140- PM �?. -ro s a Owner's Name _x Address Phone T Contractor Address ---License No.-JOS-'7,21 Phone 6 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 s i ❑ Industrial I ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ` ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout 4` U ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by 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 ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ Mo septic system permitted if public sewer is a available within 200 feet.] �i Installation will serve: Residence� Commercial— Other ap f ar �. Number of living units: 00- Number of bedro°m s � ✓ f Character of soil to a depth of 3 feet: A76- LOA^ Water table'depth SEPTIC TANK CY Type/Mfg CO A; - to atG f&G Capacity_JJ.J;_Q No. Compartments PKG. TREATMENT PLT. ❑ '3-KMethod-of-Disposal Distance to nearest: Well 10-113� Foundation 35 Property Line A f 1 # LEACHING LINE r OL1 No. & Length of lines ,Total length/size / � O' FILTER BED ( Elbistance to nearest: Well Foundation.- Property Line SEEPAGE PITS 171/Depth vZ f Size f Nunnber SUMPS # ❑ Distance to nearest: Well Foundation 51 � Property Line Q� 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 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 ralf re uire inspections. Complete drawing on reverse side. , ,�r - Signed Title: 1& A)CA a Date: eZ .23 U FOR DEPARTMENT USE ONLY Application Accepted by """ _T _ �'` r � ate Area r Pit or Grout Inspection by � � Date Z q ~' -Filial Inspection by Date f „ v Additional Comments: ❑ Stk' 466-6781 Loi1i 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8354M Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT N0. INFO 1, + EH 1324(REV.s/a sus E 3 f�� f EH 1428