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i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT g 1601 E. HAZE.T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED �s (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct andlor 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 r U ,e _ Gity� L t Size PM t u Owner's Name "' `' ddress �_ C Y _ Phone Contractor Address License No. Phone TYPE OF WELL PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ V DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL l PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I f" C1 Industrial El Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ` 171 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Publico ❑ Other] ❑ Delta Depth of Grout Seal Type of Grout t I I Irrigation M --Approx. Depth I i Eastern Surface Seal Installed by . Repair Work Done ❑ Type of Pump H.P. State Work Donee f Well Destruction t❑` Well Diameter Sealing Material Itop 501 Depth ) Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I'I REPAIR/ADDITION i I DESTRUCTION (No septic system permitted it public sewer is available within 200 feet.) Installation will serve: ResidenceL 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 L PKG. TREATMENT PLT. ❑ Method of Disposal I Distance to nearest: Well Foundation Property jLine LEACHING LINE ❑ No. &'Length of lines -Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I'] Depth I Size Number SUMPS L1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑. 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 I certifies the following:"I certify that in the performance of the work for which this permit is issued,l shall employ persons subject to workman's compensa- tion laws of California." - - • -t} iIi The applicant ust cal! fora equired inspections. Com late drawing on reverse side. � ` �,. � i Signed X Title: " Date: 140�e / FOR DEPARTMENT USE ONLY Application Accepted by li✓ Date ~ $� Area 11 R Pit or Grout Inspection by Date Final Inspection by ? ,Data i Additional Comments: O`t✓J z 171Stk 466-6781 ElLodi 369--3621 ElManteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Envi nme tar Health Permit/Serv, es 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 Ir^ /G A e7 er� �/ S l21 rrh j7- I� , S �J -71FEE INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'No. + EH 13-24(REV.i i a 5) EH 14.28