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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 (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 r made in compliance with San Joaquin County Ordinance No.549 for sewage or No.'1862 for well/pum Local Health District. p and the Rules and Regulations of the San Joaquin ' Job Address Cit)' Lot Size PM Owner's Name Address Phone Contractor's Name •g License No. TYPE OF WELL/PUMP: NEW WELL ElPhone WELL REPLACEMENT LJ DES TRUCTION L-1Y PUMP INSTALLATION VOTHER 173�PrEP�.gcSTEM REPAIR ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES k DISPOSAL FLD. PROP. LINE FOUNDATION.. . . AGRICULTURE WELL OTHER WELL INTENDED USE PITS/SUMPS _ TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca i ❑ Domestic/Private ❑ Gravel Pack El Tracy Dia. of Well Excavation -[iia. of Well Casing ❑ Public y Type of Casing Specifications ❑ Other ❑ Delta Depth of Grout Seal t J ❑ Irrigation ---Approx. Depth ❑ Eastern )Type of Grout Surface Seal Installed by Repair Work Done ❑ Type of Pump S(�� H p t Well Destruction ❑ Well DiameterState Work U'ne\_. Sealing Material {top 50') Depth Filler Material (Below 501) TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ fNo septic system permitted if public sewer is Installation will serve: Residence_ Commercial_ Other available within 200 feet.) t Number of living units: Number of bedrooms 1 j Character of soil to a depth of 3 feet:' SEPTIC TANK Water table depth ❑ Type/Mfg Capacity No. Compartments rn PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well FouncWti0r1 Properly-Line LEACHING LINE ' (') El No. & Length of lines ' Notal,length/size ' ❑ Distance to nearest: i Well Foundation FILTER BED n Property Line I i 4 SEEPAGE PITS �' ❑ Depth ��C!��,,Siz��J , ,�,. . I SUMPS "r'i A # Number i rs�3 ik ❑ Distance to nearest: Wel!- �.Foundation-`-�--�-- DISPOSAL PONDS ..a ❑ Propetty-L-ine Vie hereby certify that I have prepared this applicatioq.and that the work will be dope-in.accordance with San Joaquin county ordinances,`stat maws, and rules and regulations of'tha San Joaquin+L'b NealtFi-District 17�`'� Home owner or licensed agent's signature certifies the following: employ an g: ""I certify that in the performance of the work for which this permit is is;ued,,�hall not P Y Y 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 pertormance of the wark'for which this permit is issued, I shall employ persons subject to workman's compensa- tion ompensa tion laws of California." ' The applicant must call tall required inspections. Complete drawing on reverse side. Signed f } -- i Title:. -� Date: 1' . / FOR DEPAR T�IJS E ONLY I Application Accepted by 1 la ; _ Date 6 Area D Pit or Grout Inspection by --=--:--� I t 4 y'7 Date Final Inspection by Date Additional Comments: � j ❑ Stk 466-6781 2_f,_odj__W9 3621 - ? _ 1 O-Manteca 823=7104----- ©T-recy-83rg85 Applicant- Return ail copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT —.CASH,S^ INFO �+RECEIVED BY -- DA PERMIT'NO. t EH 13-24IFIEV. 70/831 'f i •-` `,. 1. '1_r:_'t -..J f. EH i426 ,. �ci d