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APPLICATION FOR PERMIT _ 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. � Job Address 7'T// 7-5 �I �O�'E �Q City � Lot Size PM T//f'1E' DIC C o, /100-f-Tax Z"tal ' S9�sPA 1��s?y Phone CR v) 771-3 a Owner's Name o Address Contractoc%Name Ro�`� /�ao7-Lg2 License No. 2066*/ Phone 6S-26/6 r 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 ( �� INTENDED USE TYPE'OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �J` ❑ Industrial ❑ 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 ❑ 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 509 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is -r available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units:_ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal _ Distance to nearest: Well Foundation Property Line LEACHING LINE Q Ne. & Length of tines 2- �� f' 90 Total length/size 4 FILTER BED ❑ Distance to nearest: Well OG-f' Foundation YO Property Line 7� SEEPAGE.PITS - E--D—,pth 2 � Size -3 3 � Number 2 SUMPS ❑ Distance to nearest: Well / w Foundation Property Line 7d li DISPOSAL PONDS ❑ 1 - I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaqui rF�icluunty ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. ' Home owner or licensed agent's signature certifies the following: 'Y 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:'=1 c that in the performance of the work for vAjich this permit is issued, I shall employ.persons subject to workman's compensa- tion laws of California." ' The applicant must all requ' in s. Complete drawing on reverse side. Signed X Title: L! Date: FOR DEPARTMkNTUSE ONLY p Qr Application Accepted by I----Date - u --,- 1 Area '1 (��Pit r Grout Inspection by Date ' 7- Final Inspection 6 Date � r Additional Comments: ❑ Stk 466-6781 ❑ Lodi W3621 Gb Mante1a 62317104 ❑ tracy 835-6385 Applicant=-.Return-all copies to: Environmental Health-Permit/Services 1601 E. Hazelton Ave., P.O. Box 2008, Stk.,9/lm1FEE - INFO 11 AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. L - S EH 1}201REV.10/991 r \ 1--rte �Ir— —— t', �— —