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. APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT- 1601 ISTRICT1601 E. HAZE T ON AVE., STOCKTON, CA '. Telephone (209) 466-6781 i PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 3 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 D �Q' (� s / City. 0 Lot Size �+ P M Owner's Name ,&_a OJ/ C6f IIGI�{�ddress tel/ !'/� SG(� _ Phone Z4!f4'_'4-vn.2 Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ _ _ OTHER ❑ DISTANCE TO NEAREST:-SEPTIC TANK -� SEWER LINES DISPOSAI FLfI. PROP:LINE""'•"" FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r INTENDED USE TYPE OF WELL PROBLEM AREA- CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Ria- of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy `Type of Casing Specifications /a k ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I f Irrigation _.-Approx. Depth i I Eastern Surface Seal Installed by y Repair Work Done 71 Type of Pump R H.P. State Work Done Well Destruction ❑ Well Diameter i Sealing Material Itop 501 y Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION 1-1 DESTRUCTION (No septic system permitted if public sewer is , r - . available within 200 feet.h Installation will serve: Residence_s Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: k Water table depth SEPTIC TANK ❑ T e/Mf ' YP 9 Capacity No. Compartments � PKG. TREATMENT PLT. ❑ I Method of Disposal l 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 ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ t i hereby certify that I have prepared this application and that the work will.tie done in accordance with San Joaquin county ordinances, state laws, an rules and regulations of the San Joaquin Local Health Dil;trict. y 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 shalt not employ any person in such manner as to become subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature 1 j} 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 equired inspections. Complete drawing on reverse side. r o Signed X Title: �d � 0 _ Date: FOR DEPARTMENT USE ONLY Application Accepted by Data Q Area © „_ Pit or Grout Inspection by Date Final Inspection by Additional Comments: ❑ Stk 466-6781 ❑ odi 369-3621 ❑ Manteca 823-7104 LI Tracy 835-6385.. Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE r AMOUNT REMITTED RECEIVED BY DATE PERMI7'NO. +.EH 14-24IREV.rine)