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F APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES VYEAR 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. 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 mph Contractor dzy, Addres c�� 44, Licensa Ph e --s �-/ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ s SYSTEM REPAIR ❑ — OTHER ❑ --� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SP ATIONS i ❑ Industrial fl Open Bottom ❑ Manteca Dia. of W cavation Dia. of Well Casing a ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy a of Casing_ Specifications 1-1 Public F Other [ ) De Depth of Grout Seal Type of Grout 1 1 Irrigation _.Approx. D _11 Eastern Surface Seal Installed by Repair Work Done ❑ Type mp H:P State Work-Done Well Destruction Well Diameter -Sealing Material (top 501 Depth Filler Material (8elow-501 YPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION I I DESTRUCTIO (No septic system permitted if public sewer is \�\ vailable within 200 feet.) Installation will.serve: Residence Commercial_ Othet Number of living units: Number of bedrooms 1 ` j Character of soil to a depth of 3 feet: Water table depth i SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments i PKG. TREATMENT-PLT. ❑, Method of Disposal j Distance to nearest: Well Foundation Property Line f LEACHING LINE ❑ No. & Length of lines Total length/sizeµ FILTER BED ❑ Distance to nearest: Well Foundation Property Line r A SEEPAGE PITS I"I Depth Size Number SUMPS Ll 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 I 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 applicant ust call for ell required inspections. Complete drawing on suers Signed F Title: Date: t F( ARTMENT USE ONLY Application Accepted by / Date Area }� Pit or Grout Inspection by Date Final Inspection bye Date v Additional Comments: !) ❑ Stk 466-6781 0 L& 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bdx 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT•No. INFO L `I CASH a EH PA 11474 13-24(REV.i/H5) •+(' 3St EH t4-2a