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APPLICATION FOR PERMIT f' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1'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. v-- 3 v 1 cr-�� Job Address / r �' Ci T Lot Size PM Owner's Name a14Address 2E Phone r y Contractor ss �0 l40c�nse No.X77 Phone TYPE OF WELL/PUMP: NEW WEL WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION �If SYSTEM REPAIR„_❑l: .w_.� OTHE ❑ _ � _ / bISTANCE TO NEAREST:,SEPTIC TANK �� -� SEWER LINES."4y� DISPOSAL FLD� PROP.-LINE FOUNDATION t AGRICULTURE WELL OTHER WELL PITSISU6-S INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO ❑ Industrial pen Bottom i 71 Manteca Dia. of Well Excavati n Dia. of Well Casing I] Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M,Pu�bl-� :, i”" n'Other _ Cl Delta Depth of Grout Seal Type of Grout F1'frrigation 4 ""—''Approx. Depth i I Eastern S irface Seal Installed by _ -Repair Work Done' D Type'eof Pump H.P. State Work Done Well Destruction ;4� ].__Well�Diamet4 r h Sealing M erial {top 50'1 j Depth F Filler Material (Below 501 TYPE OF SEPTIC WORK: NEIN INSTALLATION I 1 RLPA114/ADDITION (.I DESTRUCTION I 1 INo septic system permitted if public sewer is } _ M t available within 200 feet.) "` r Installation will server Residence Y Commercial . Other Y Number of living units: Number of bedrooms Mme" k` ? y3 4 s r Character of soil to a depth of 3 feet: 1 Water table depth SEPTIC TANK t ❑ Type/Mfg Capacity uT No. Compartments f r PKG. TREAT�MENTIPLT:.,f14L<-"-" """"" ""'" ~� Method of Disposal + Y J Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line i SEEPAGE PITS i I Depth Size__ Number ` SUMPS Cl 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, stale 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 mu call for a requi mspe tions Complete drawing on re se side. �[ Signed X �'�-' Title: TQ Date: 7 FOR DEPARTMENT USE ONLY / Application Accepted by ! ' Date ��1 Area O Pit or Grout Inspection Date'q�8` Final Inspection by Z4 Date Additional Comments: ❑ Stk .466-6781 ❑ Lodi 369-3621 ❑ 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 9 CASH RECEIVED BY DATE PERMI5iV ' INFO + + a EH 13-24 IREV.1/8 51 ✓I 1 � _6-1 � j EH 14-26 {{{ 1� II! JkM 1 (�V�`