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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 12091 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i (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 San4Y 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 �d d L City Alitiot Size PM Owner's Name P til -Phone 4 Contractor �I Address License No. Phone TYPE OF WELL/PUMP: i�' NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE "F,OUNUATION X_ 5r�AGRICl1LTlJREWELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM�AREA.,-CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑`Open Bottom ❑ Manteca ,,`" Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy r` Type of Casing Specifications r,t ❑ Public ❑ Other 0,D'elta h of Grout Seal Type of Grodt ❑ Irrigation Approx. Depth�'O Eastern Surfac , eal Installed by r 0' Repair Work Done ❑ Type of Pump /r H.P. State Work Done Well Destruction .❑v__.1/Vell..Diameter..- -- - .._Sealing.Material-(top-50T, Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is } available within 200 feet.) 1_ Installation will serve: Residence� Commercial_ Other I Number of living units: Number of bedrooms +. Character of soil to a depth of 3 feet: Water table depth V SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments I/1 i PKG. TREATMENT P!T'. ❑ —r- - _ _. _. .._ __ ____.. ._._ . _ -_ - Method of Disposal Distance to nearest: Well _ Foundation, _Property Lime. LEACHING LINE ❑ No. & Length of lines Total length/size 0 FILTER BED ❑ Distance to nearest: Well l� Foundation Property Line SEEPAGE PITS ❑ I Depth Size Number SUMPS ❑. 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 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." III The applicant m t call for all required inspections. Complete drawing on rreverse side. r Signed - Title: Date: _V VY; FOR DEPARTMENT USE ONLY Application Accepted by Date Are Pit or Grout Inspection by Date Final Inspection b7i' Date i 11 d`. Additional Comments: 0 Stk 466-6781 ❑ odi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6388- Applicant- Return aII copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY y DATE PERMIT`NO. + EH 1426(REV.Fla5) ` �� .?�( / 7 �,..7