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S I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT t 1601 E. HAZELTON AVE., STOCKTON, CA Lf Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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 sS �1 Lot Size pr PM Owner's Name !1 hE� ! Address �4�,. �K Phone Contractor Address License No. Phone TYPE OF WEL /PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAR ES TIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE I� FOUND N AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL OBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Mant Dia- of Well-Excav tior5 --- -- - Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Ing Specifications l Public f1 Other ❑ Delta epth of Grout Type of Grout I Irrigation _._Approx. Depth I I East Surface Seal Installed by - Repair Work Done ❑ Type of Pump H. P. State Work Done — `u Well Destruction ❑ ' Well Diameter Sealing Material (top 50') (� Depth Filler Material (Below 50'1 -- TYPE OF SEPTIC WORK: NEW INSTALLATION i a REPAIR/ADDITION ( I DESTRUCTIO (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 SEPTIC TANK ❑ TypelMfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ ` Method of Disposal Distance to nearest: We ""` Foundalion PropertV Line LEACHING LINE ❑ No. & Length of lines : Total length/size FILTER BED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I Depth Size Number SUMPS Cl 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." r The applic ust c l for all required inspections. Complete drawing on reverse side. Signed X Title: Ou,V"',.✓ - Date: FOR DEPARTMENT USE ONLY f�] Application Accepted bDate Area r Al-' l Pit or Grout Inspection mEDate Final InspectiLon by r _ Date Additional Comments: 4 Z k �� trl w ❑ Stk 466-6761 ❑ Lod' 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-d85 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 yn FEE AMOUNT DUE AMOUNT REMITTED A RECEIVED BY DATE PERMIT NO. I INFO //�� J ra�ry �/p ♦.EH 13-24(REV.1/45) '�V -7Q + +5 ��` 1•, EH 14-28