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APPLICATION FOR-PERMIT SAN JOAQUIN LOCACHEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 F PERMIT EXPIRES 1-YEAR FROM DATE ISSUED a (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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address C' � A 4.2 City O � Lot Size PM Owner's Name 11";S 1511;16 Address —'13 67 Gci '/1C.� Phone Sri- S:0-2 6 Contractor AddressLicense No. Phone TYPE OF WELL/PUMP: NEW WELL.❑ WELL REPLACEMENT O w_©ESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR-❑ 9. OTHER ❑ DISTANCE TONEAREST: SEPTIC-TANK - - SEWER LINES DISPOSAL FLD. PROP. LINE # FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca -Dia- of Well Excavation T Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing I Specifications M Public F1 Other M Delta Depth of Grout Seal Type of Grout i I Irrigation ---Approx. Depth I 1 Eastern Surface Seal Installed by V] Repair Work Done ❑ Type of Pump H,P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50'1. Depth p Filter Material (Below 501 - n� TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION LI 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 feet: Water table depth SEPTIC TANK ❑ 'Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal `Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size r FILTER BED 11 Distance to nearest: Well Foundation Property Line SEEPAGE PITS i I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line F 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. 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 appliall required inspections. Complete drawing on re arse side. Signed X= Title: Date: J— FOR DEPARTMENT.US ONLY Application Accepted by Date U Area Pit or Grout Inspection by Date Final Inspectio Datd� Additional CommentsVL] ocdri� ❑ Stk 466-6781 �30 teca 823-7104 ❑ Tracy 835-6385 Applicant • Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY INFO DATE PERMIT'NO. + EH 13-24(REV.1/8!5) EH 11-29 r�7