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APPLICATION FOR PERMIT R` 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. 16 Jr- Y Job Address _ City,; �Ll-iLLot Size PM Owner's Name ' . Address / ftp -` Phone kO � Contract ddress -_ p �',,�i .: ,+�, License No. /,m�•fa i Phone TYPE OF WELL/PUMP: NEW WELL ❑- WELL REPLACEMENT ❑ DESTRUCTION ❑ f r PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ III DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMP'S 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 Type of Casing Specifications 171 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout _ I I Irrigation_ —'Approx. Depth, I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _ G Well Destruction Cl— Well Diameter Sealing Material (top 501 -Oepth Filler Material (Below 501 100 TYPE OF SEPTIC WORK: NEW INSTALLATION I'1 REPAIR/ADDITION I i DESTRUCTIO . iNo septic system permitted if public sewer is r _ _ available within 200 feet./ Installation will serve: Residence— Commercial_ Other t:-- Number of living units: Number of bed#ooms * s Character of soii,to a`depth of 3 feet: - Water table depth SEPTIC TANK .. 'V 0 -Type/M19 1 y Capacity No. Compartments ` 9 PKG. TREATMENT PLT. C1 f Method of Disposal Distance to nearesu, Well Foundation Property Line i LEACHING LINE ❑ No. & Length of lines "Total lengtth/sizeLA j FILTER BED © Distance to nearest: ,. Well Foundation Property Line _^ SEEPAGE PITS 11 Depth Size Number I 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 countyordinances, state laws, and rules and regulations of the San Joaquin Local Health Di�trict Home owner or licensed agent's signature certifies the fallowing: "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, 1 shall employ persons subject to workman's compensa- tion laws of California." -p-- The applic u t call fpr al T'-qutrel"inspections. Complea'e drawing_0_nZ`_,_erse side. 'w Signed X �' 4A Title: r `3 ty y. r hse Dates FQR DEPARTMENT USE ONLY Application Accepted by -�� — Date Area I! Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lode 369-3621 ❑ Manteca 823-7104 ❑ Tracy 935-6385 mm� Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton'Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY GATE PERMIT`NO. t..EH 13.24IREVV.1/H5) EH 14-28 / ��