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APPLICATION FOR PERMIT _SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 } PERMIT EXPIRES TYEAR FROM DATE ISSUED I (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 ,Vo ' 8 La-►e- CityOC// Lot Size PM j Owner's Name Yom• Address -77 Phone t Con tractor�wi.t/iiyG� L-VWC Address 2SZ 7 6�41 f-i ?�IFcense No to 12 Phone _10 Z, 1 i 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 o FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS f INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS a ❑ Industrial ❑ Open Bottom ❑ Manteca Dia_ of Well Excavation Shu pia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing J Specifications O � _{ f'1 Public n Other F1 Delta Depth of 6+eut Kesel"� /S Z Type of Grout�/r �'c.�_ 1 1 Irrigation --Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _ Wellpestruction/ ❑ Well Diameter Sealing Material (top 50'] / �G /,• Depth Filler Material (Below 50'I TYPE OF'SEPTIC WORK: NEW INSTALLATION I.] REPAIR/ADDITION l I DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) Installationwill serve: Residence— Commercial_ Other 1 Number of living units: Number of bedrooms f Character of soil to a depth 3_feet: Water table depth SEPTl9 TA K ❑ Type/Mfg Capacity 'No. Compartments PKG. TREAT ENT PLT- ❑ Method of Disposal ' 1 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,] Depth Size _ Number SUMPS L� Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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. I 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- q tion laws of California." The applicant must ca or all required • spections. Complete drawing on reverse side. Signed X Title: e�n ✓Y Date: t E USE ONLY r iJ.- <,, i Application Accepted b Data ! rea !7 Gel. .rBti- Pit rou pe by Dat Final Inspection by A itiona Comment: ❑ St k 466-6 1 ❑ L 1 369 1 ❑ Manteca 823-7104 ❑ Tracy 63 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton A ., P.O. Box 2009, Stk,, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO 2 AS + EH 13-24(REV.i/H5) ( J� EH 14.26 t l i Is+y /g C" tm nAkM mty dl