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Ili .-_ _. -�-..�+......a• .—a.-�..... �.�r.+�-.•.r-` _ ^.c. -`.'"TQ APPLICATION FOR PERMIT -" $AN JOAQIJIN LOCAL HEALTH DISTRICT 1601 RMIT E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6181 PEEXPIRES 1'YEAR FROM DATE ISSUED 1l (Complete in Triplicate) I 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 I 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. Job Address ep' - (/�2y � 7— City 4 Lot Size PM Owner's Name � /r (7 �}i' ' �ZAddress 3.4 /f� �Y��h �- `' .�J��U79_�� Phone Contractor _ '• Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑- OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK _ YY SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION �p _ 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 ❑ Tracy Type of Casing Specifications !, I"1 Public ❑ OtherEl Delta. __._.- Depth,ofv-Grout,Seal Type of Grout _ W I I Irrigation __Approx. Depth' _ l I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter dY�Y Sealing,Material (top 50'► " Depth Filler Material (Below 50') TYPE.OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTIO (Nonseptic system permitted if public sewer is �{ /NIT. Ivailable within 200 feet.) ` Installation will serve: Residence— Commercial_ Other Number of living units: Number of beppdrooms J Character of soil to a depth of 3 feet: �JuUp Water table depth U SEPTIC TANK ❑ Type/Mfg 9P Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line SII LEACHING LINE ❑ No. & Length of lines ti Total length/size FILTER BED ❑ Distance to nearelt: Well f Foundation Property Line 'IN SEEPAGE PITS I I Depth Size Number SUMPS U 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. W 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 inspectioNllllns. Complete drawing on reverse side. Signed r �N Title: '61 22,oCr' 19 Date: FOR DEPARTMENT USE ONLY Application Accepted by _ Date Area— Pit or Grout Inspection by �Jf Date Final Inspection by Date Additional Comments: / / �7. /fr�� S S, 9C/9 ❑ Stk 466-6781 El 369 3621 10 Manteca 823-7104 ❑ Tracy 835-6385 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 RECEIVED BY INFO CASH DATE PERMIT NO. +.EH 13-24(REV: i e 5) EH 14-28