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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ,�•� 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED C (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 c: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 city Lot Size PM Owner's Name '!� ! Address Phone L 4 Contractor —' -Address License No. Phone TYPE OF WELL/PUMP: ill to NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP�NSTALLATION 171SYSTEM REPAIR ❑ OTHER ElDISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ! il DISPOSAL FLD. ff:PROP. LINE q. «- -- OTHER WELL PITS/SUMPS FdUNDATION AGRICULTURE WEL'C- INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ! ❑ Industrial ❑ Open Bottom 1-1MantecaDia. of Well Excavation Na. of Well Casing i 1 Z •, ❑ Domestic/Private E3Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal. Type of Grout r ❑ Irrigation —�fpprox. Depth ❑ Eastern Surface Seal Installed by I Repair Work Done El Type of Pump H.P. k State Work Done 4 I Well Destruction ❑ Weil Diameter Sealing Material {top I Depth Filler Material (Below 501 r TYPE OF SEPTIC WORK: Ni INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIO (No septic system permitted if public sewer is f I vallable within 200 feet.) € '/ #fi N Installation will serve: Residence� J`( Commercial_ Other I Number of livingunits: l�' �N m er of bedrooms I Character of soil to a depthiiof 34eet: Water table depth ` SEPTIC TANK ❑ IType/Mfg Cap ity " No. Compartments PKG. TREATMENT PLT. ❑ ? Method of Disposal i Distance to nearest: Well Foundation Property Line ' j j! I LEACHING LINE ❑ No. &Length of lines Total length/size FILTER BED 17 !Distance to nearest: Well Foundation Property Line t :j SEEPAGE PITS ❑ Depth Size Number f SUMPS ❑ , 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. �, y� Home owner or licensed agent's signature certifies the following, "I certify that In,thA rformance 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- r tion laws of California." i The applicant must call for all'requi inspections. Complete drawing on reverse side. Signed '^- Title: Date: I� FO DEPARTMENT USE ONLY ` } i 1 Ci n Area C3 A lication Accepted b Date Pit or Grout Inspectio Ii Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Ladi 369-3621 ❑.Manteca 823-7104 ❑ Tracy 8354335 d Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTE0 CK' RECEIVED BY DATE PERMIT"NO. INFO �I 35 + EH1 (REV,1/ w EH 14-284-28 _ - �I \?