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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL"HEALTH DISTRICT 1601 E. HAZE'LTON AVE:' STOCKTON, CA Telephone (209).-466-6781•,_ y _;. ,_ ter. ... D, ...:ry•. .. _ PERMIT EXPIRES_1-YEAR-FROM DATE ISSUED h>c - (Complete in Triplit;ate)ii„- i' • . ... �qr,,:. !t Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described;Thes.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. . y3z/ N, `�oi- 1570e<joy Job Address City Lot Size " PM Owner's Name _ �1 -' " Address �Yeo �2'Phone - - �«✓�� tic y/y: Contractor Address �l '�'"`"'' ��r 3Z License No. Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Y'd�d'G► f!o`i ri 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 SPECIFIC/%D2NS ❑ Industrial O Qpen Bottom ❑ Manteca Dia. of Well Excavati9� Dia_of WeR Casing ❑ Domestic/Private Gravel Pack. - __ ____0.Tracy _ Type of Casing / // 4 Specifications--- ❑ Public -7❑ Other ❑ Delta Depth of Grout Seal _Jype of Grout ❑ Irrigation _ �S Approx. Depth ❑ Easter Surface Seal Installed by!:)(C -- — Repair Work Done _❑ Type of Pump. H.P. State,Work Done Well Destruction ❑ Well Diameter Sealing Material(top 50') - Depth Filler Material(Below 501 TYPE OF SEPTIC WORK:. NEW INSTALLATION ❑ .REPAIR/ADDITION ❑. DESTRUCTION ❑-(No septic system permitted if public sewer is _. 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 fee..' --- _--- - ___ _....--.--__. _ - - .-•--. -Water table depth --- -- SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments ^ PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING UNE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ 1Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑: __ _. ..•. . ._ -.-•-- .-,--_... ._.-t_ -. ..._ - _._._.. 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 ist cal for reAuir inspections. Complete drawing'reverse side. Signed !tip 1�l Titlec.��ri�.•+��rf./ �o�/c. �/ �-/� ff�7 . Date: USE ONLY Application Accepted L%'` 7?- Date Area Pit or Grout Inspection Date Final InspectiDn by to Additional Comments: .Cctin_ ❑ 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 INFO CASH RECEIVED BY GATE PERMIT NO. . EH 132 (REV.t 115-, S• U C' / 6`7-1771a 177}a