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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E."HAZEL T ON•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 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. rJ/ f.Iy J �(� City L�( Lot SizeZ-7�X�(p V PM Job Address r `�- �� l h R'O a 1 Lt,�cPhone 3 (/71 Owner's Name L — Address I /A Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL 9�, WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ; + FOUNDATION - AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE ' TYPE OF WELL F PROBLEM AREA CONSTRUCTION SPECIFICATIONS + 171 Industrial C1'Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other # ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation -L--Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump + H.P. ' I ` State Work Done Well Destruction ❑ Well Diameter Sealing Material [top 50') t r Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is t ii available within 200 feet.) Installation will serve: Residence 4 , Commercial— Other I t { Number of living units: Z Number of bedrooms Character of soil to a deYpt�of 3 feet: ��'r ' Water table depth SEPTIC TANK L�' Type/Mf Capacity No. Compartments i f i YMethod of Disposal PKG. TREATMENT PLT. ❑ ! Distance to nearest: Well b l Foundation l Property Line_�Q LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED,-,;'-/ ❑ Distance to nearest: Well f 2.5� Foundation� Property Line SEEPAGE PITS ❑ Depth �n,, t- Size Number SUMPS ❑ Distance tWe!! Foundation Property Line DISPOSAL PONDS ❑ ; hereby certify that'l 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 compense- tion laws of California." The applicant must call for all require 'n s. Complete drawing on reverse side. I Signed Title' x T Date: 1 FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date A Final Inspection by Additional Comments: ❑ Stk 466-6781 odi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazekon Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY D TE PERMIT NO.-._ INFO z Ji + EMI 3-24 TREY. s 51 EH 14-28