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APPLICATION FOR PERMIT l k SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA 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 AddressC Lot Size PM i Owner's.Name r Address Phone Contractor -", Address License N Phor I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL MPS INTENDED USE TYPE OF WELL PROBLEM AREA- GONSTRUCTiON CATIONS { ❑ Industrial 0 Open Bottom 0 Manteca Dia. Excavation Dia. of Well Casing f ❑ Domestic/Private El Gravel Pack ❑ Tracy Type of Casing Specifications II I"1 Public ( i Other l l a T Depth of Grout Seal i Type of Grout NA I I Irrigation _.-Approx. D i I Eastern Surface Seal Installed by - Repair Work Done ❑ Type mp H.P. State Work Done _ r` I ` Well Destruction 0 ell Diameter Sealing Ma11 terial [top 50') V Depth Filler Maierial (Below 501 i TYPE OF SEPTIC WORK: • NEW INSTALLATION I 1 REPAIR/ADDITION I'i '`DESTRUCTION F o septic system permitted it public sewer is F 3 available within 200 feet.] 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 �y SEPTIC TANK _❑ Type/Mfg Capacity No. Compartments ' PKC. TREATMENT PLT. Method of Disposal L� Distance to nearest: Well Foundation I Property Line LEACHING LINE ❑ No. & Length of lines ; »y. " `� Total length/size i FILTER BED ❑ Distance to nearest: Well F Foundation Property Line SEEPAGE PITS 1 I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ k x3 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'thi5'Qv6rk f6:VwhidK this perrnif is issuea,I_shall employ persons subject to workman's compensa- tion laws of California." ? y The appiica �ust �forrequired�' t s. Complete drawing on r a side. E r0 I _ Signe Title: ��_�-�� - Date. FORD ARTMENT USE ONLY 7� / Application Accepted by . Date J Area Pit or Grout Inspection by Data Final Inspection by Data Additional Comments: 171ho Stk 466-6781 ❑ Lod' 369-3621 11Manteca 823-7104 ❑ Tracy 635 6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO Q, CASH Z> + EH 13-24(REV"'t/x 5) ]�' � _ / � r 'EH 14-26 'O - t� C