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f APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1.601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-67$1 PERMIT EXPIRES #'YEAR FROM DATE ISSUED (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. 1B62 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. , City a Lot Size PM' 'y Job Address � �/� � qq (It'/Ld�.�.�eL � ► C� Phone Owner's Name Address ,c Contractor �Sb� t l-r Address J_r11_e License No. �'o Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC-TANK SEWER LINES DISPOSAL FLO. ROP. LINE ` FOUNDATION -AGRICULTURE WELL ELL s PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CO TION SPECIFICATIONS c ❑ industrial ❑ Open Bottom ❑ Mantec Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack racy Type of Casing Specifications M Public Ll Other 1=l Delta Depth of Grout Seal Type of Grout _ I I Irrigation prox.'Depth. .l I Eastern Surface Seal installed by t Repair Work Done ❑ Type of Pump H.P, State Work Done Well Destruction ❑ Well Diameter Sealing Material(top 501 C Depth Filler Material (Below 501 G TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION t I DESTRUCTIO (No septic system permitted it public sewer is available within 200 feet.) Installation will sere: 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'F'LT. ❑ Method of Disposal t 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 SEEPAGE PITS I 1 Depth Size Number SUMPS n ❑ - 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-arid regulations of the San Joaquin Local Health District. Home o%ner 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 pgrfgrmance.of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." T The applicant must call for all required inApections. Complete drawing on reverse side. Signed X - - Title: Date: FOR DEPARTMENT USE ONLY '] i Date i' �� +� Area Application Accepted by ' Pit or Grout inspection b Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lo I .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 r FEE AMOUNT DUE AMOUNT REMITTED CK C SH RECEIVED BY DATE PERMIT'NO. INFO /�(' /{! r //c��J(►//y ..EH13-24IREV"i/'K 51 EH 14-26 ✓