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APPLICATION_ ION FOR PERMIT SAN JOAQUIIN LOCAL HEALTH DISTRICT i 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 I 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 Aro,549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin i Local Health District. Job Address -i-; City Lot Size PM Owner's Name 6 �.:.U%l r ti.t. tiL� J.._E l.ii.. i Address J I ! _ ;r 1,1! } Phone "��'J- •ConVactor Address 1, 70 ,,r„ License No. : ].,., , Phone L7`r, TYPE OF WELL/PUMP: NEW WELL L),; WELL REPLACEMENT ja DESTRUCTION.,f1 PUMP INSTALLATION Q SYSTEM REPAIR 0 OTHER El DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES , -J� DISPOSAL-FLD. l PROP. LINE 1 FOUNDATION AGRICULTURE WELL OTHER'WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial Cl Open Bottom ❑ Manteca Dia. of Well Excavation 1 Dia. of Well Casing _ ❑rpomesticlPrlvate ❑Gravel Pack ❑ Tracy Type of Casing ��'� Specifications F] Public F1 Other C1 Delta Depth of Grout Seal I 1 Irrigation Type of Grout_._� `; 0 .Approx. Depth I 1 Eastern Surface Seal Installed by. j�-'�;-+• .,-'-, --. Repair Work Done I] Type of Pumps M.P. - State Work Done Well Destruction © Well Diameter Sealing Material atop 501) Depth Filler Material (Below 5011 TYPE OF SEPTIC WORK: NEW INSTALLATION E I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is Installation will serve: Residence— Commercial, Other available within 200 feet.) l Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth y SEPTIC TANK ❑ Type/Mfg Ca acit P Y No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Cine LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED D Distance to nearest: Well Foundation Property Line SEEPAGE PITS i I Depth Size Number SUMPS C] Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ i 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. 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 giall for all to 'red inspections. Complete drawing on reverse side. Signed X Title: '.�V! "'tf Date: 7-31—o FOR DEPARTMENT USE ONLY Application Accepted by f Date 3 a3 ,k Area t Pit orGrau Inspection by at Final,Inspectio by rrr??? Date E Additional Comments: ❑ Stk 456-6781 0 L i 369-3621 ❑ Manteca -7104 , t,O Tracy' 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave„ P.O. Box-2009, Sik,, CA 95201 ♦ti y.. �5N FEE AMOUNT DUE AMOUNT REMITTED l` INFO CASH RECEIVED BY DATE77 Pi RMIT N0, i Sr + EH 1 .24 1REv.1 i H 51 ��] EH 14-2e /3 S.S