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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE-ISSUED a . ,+(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 ddeescribed."TNs applicati n 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. q - Job Ad dre55 City Lot Size Q PM 1� I Owner's Name f A" Address 333,921G; Phone Contractor Address License No. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 0 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE li TYPE OF WELL —PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ;if❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia' of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casingi Specifications r ❑ Public ! ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by 1 Repair Work Done ❑ Type of Pump H.P- State Work Done Well Destruction ❑ !i Well Diameter Sealing Material [top 501 Depth Filler Material 18elow 501 TYPE OF SEPTIC WORK': NEW INSTALLATION E. REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial_ Other > Number of living units:', Number of bedrooms Character of soil to a depth of 3 feet: -- Water table depth f SEPTIC TANK Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. O Method of Disposal Distance to nearest: Well Foundation Property Line it LEACHING LINE D No.-& Length of lines Total length/size ? FILTER BED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth s Size Number SUMPS. i] 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. -c 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." I The applican must call for all required ins actions. omplete drawing on reverse side. 1 �+ X Signed ' Si _ _ Title: g Data: FOR DEPARTMENT USE ONLY Application Accepted by Q� Date Area Pit or Grout Inspection Date Final Inspection by *�� Date �r " Additional Comments: � �r V� " ❑ Stk 466-6781 ❑ i,Lod, 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 i FEE— AMOUNT DUE AMOUNT REMITTED INFO CASH-- RECEIVED BY DATE PERMIT'NO. 3 t EH 7}241REV.i/xsY EH 14-26