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r C' APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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. City A✓ Lot Size PM Job Address Phone Owner's Name _ 1 Conti actor,F,C"P 67. (AleOZ Address—7 Al- � L� T License NO.��`r�~'7 Phone ��'� �� TYPE OF WELL/PUMP:. NE_W WELL 171WELL REPLACEMENT DESTRUCTION Ll �y PUMP INSTALLATION 171 REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST:"SEPTEC"TANK-'a"""""""— "SEWER LINES DISPOSAL FLD.- PROP. LINE I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS s ' INTENDED USE TYPE OF,WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial r ❑ Open Bottom ❑ Manteca I t Dia. of Well Excavation Dia. of Well Casing t 4 s, K ❑ Domestic/Private 3 ❑ Gravel Pack v * ❑ Tracy Type of Casing Specifications [l Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout — I I Ifrigation I � .Approx. Depth 4 I Eastern Surface Seal Installed by - �,,H..P,---� — - a'- State Work Done Repair Work-Done ,�❑—Type-of-Pump-- �----- - - � ` Well Destruction ❑ Well Diameter Sealing Material (top 501 I Depth Filler Materiall(Belaw 50'i 4 ; TYPE OF SEPTIC WORK: NEW INSTALLATION I:I REPAIR/ADDITION iJ DESTR TION (N.seilabptic's n 200 feet.) if'public sewer is Installation will serve: Residence r Commercial Z Other I Number of livin units: Number of bedrooms r g �-� // Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg 'Capacity No. Compartments Yf , PKG. TREATMENT PLT. 11Method of Disposal Distance to nearest: Well Foundation F Property,Line it LEACHING LINE ❑ allo. &.Length_of lines_ Total length/size FILTER BED' ❑ Distance to nearest: Well Foundation Property Line t SEEPAGE PITS VNumber I Depth Size F SUMPS ❑ 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 i rules and regulations of the San Joaquin Local Health District. i 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 pefson 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 inspectlons. Co to drawing on reverse side. Signed .)f .t�� r r'Title: t Dater FOR DEPARTMENT USE ONLY i,J11} ti Date '0~ Area �+ Application Accepted by l 1611 � l Pit or Grout Inspection y I ate Final Inspection by Date f 4 Additional Comments: , ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835- 1 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK H RECEIVED BY DATE PERMIT'NO. INFO ` + EH 13- 1REV, EH 24