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Rtl APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone(209)466-6781 PERMIT EXPIRES I YEAR FROM DATE ISSUED IComplete 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 Sen Joaquin County Ordinance No.549 for sewage or No.1812 for welllpump and the Rules and Regulations of the San Joaquin Local Health District. Job Address w tie rti{CS�Q fs Ciry��__ Lot Sze _ PM Owner'sName 1 f� ��>�e r 1 C'S (/Address )1:1 L w-zk-_` �ff�f j Phone Contraetoo�- i_ • �_'e-IA r Address,4f- 13 i P..;1!t License No, Phone TYPE OF WELLIPUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHFA ❑ 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 S ❑Industrial ❑Open Bottom ❑Manteca Dia.of Well Excavatio Dia.of Well Casing � 15(xevomestic/Private ❑Gravel Pack 17 Tracy Type of Casing SCh' it PUf� Speaitrcations e rot,im ❑Public Y4gther ❑Delta Depth of Grout Seal S1,_----� Type of Grout ❑Irrigation _ �4nprox.Depth ❑Eastern Surface Seal Installed by ��+� f s Repair Work Done ❑ Typo of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material(top 50) Depth Filler Materia!(Below SIT) TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION❑ DESTRUCTION❑ (No septic system permitted if public sower 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 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No.Compartments { PKG.TREATMENT PLT.❑ Method of Disposal j Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No.&Length of lines Total lengthlsiza FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ t 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 pennit is issued,I shall not employ any porion in such mannar as to become subject to workman's compensation lam of California."Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the 4vark for which this permit is issued,I shalt employ persons subject to workman's compermit- tion laws of California." The applicanVinirt call for requi ed ins ec i Tete drawing`on reverse icle. ,G_� _ Signed Y Title;G S�urG(J� Date; FOR DEPARTMENT USE ONL y Application Accepted by �" " �-`"i- Date Area__ZV - -- -T_ Pit or Grout Inspection by-- Data Final Inspection Date Additional Comments: .f �U- - ❑Stk 4W,-MI ❑Lod) 1 ❑Manteca 8237104 ❑Tracy 825-6385 3 Applicant-Return all copies to:Environmtsntal Health Penn it/Services 1501 E.Hazahon Ave.,P.O.Box 2008,Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CA i, RECEIVED 8Y DATE PERMIT'NO. •FH t32�tREY.f,a er ` r�:PJ FiI 1420 // �f I` G 7