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i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT {, 1601 E. HAZEL i ON 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. 7 Job Address z Yl 5c• � i r>f�� u, City TAY Lot Size PM Owner's Name 4 1` 4vr A13$&5' Address _�1/1? iwlye Phone # it O" tray. //f� /`�eclr' r Contractor � � �� SOS Address_ License No. Phone (� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ r � ' I r PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ t� DiSTAiVCF—I. NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE DATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL OBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private O Gravel Pack ❑ Tracy Type a Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout --Approx. Depth ❑ Eastern Surface Seal Installed b I .❑ Irrigation app p y Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material [top 50'1 Depth Filler Material (Below 50'1 \� i IV\ TYPE OF SEPTIC WORK: !NEW INSTALLATION;] REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.l r7 Installation will serve: Residence / Commercial_ Other Number of living units: -__Z_ Number of bedrooms a- '' Character of soil to a depth of 3 feet: I4ckilll` Water table depth fj7 SEPTIC TANK ❑ Type/Mfg Cb,ycYC Are C^e7 Capacity 1:7_0(7 No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal - Distance to nearest: Well �' r Foundation id Property Line LEACHING LINENo. & Length of lines Total length/size f � FILTER BED ❑ Distance to nearest:" Well Foundation Property Line yC' SEEPAGE PITS ❑ Depth Size Number r ' fi SUMPS ❑ Distance to nearest: Well Foundation Property Line ` DISPOSAL PONDS ❑ I hereby certify that I have,brepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and 11 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 fallowing:"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 inspections. Complete drawing on reverse side. Signed K Title: Date: r, � OR DEPARTMENT USE ONLY v Application Acceptedby �� "" Date N /Jl f Area a Pit or Grout Inspection by �/Date Final Inspection by /" Date w-,p. ` r+7� _ ' Additional Comments: � 1 �O r7_ +t + ❑ Stk 466-6781 ❑ Lodi 369-361 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazefton Ave., P.O- Box 2009, Stk., CA 95201 i FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PEAMiT`NO, INFO CASH