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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT A07- C, 1601 E. HAZELTON ON AVE., STOCKTON, CA CrW Telephone (209) 466-6781 /7�- , 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 2District. Job Addresr!`'st� D7.�i� - City Lot Size /r �/t� PM q—� r / Address Phone .Owner's Name _ Contractor Address / d License No._13Vgaffl�Phone L TYPE OF WELL/PUMP: NEW WELL_ga7 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ j DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO."i PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation /�L/i Dia. of Well Casing ; XDomestic/Private Ll Gravel Pack ❑ Tracy Type of Casing rw� __ Specifications ` 1 hi Public F] OtF�er ❑ Delta Depth of Grout Seal lQpf Type of Gtout Gk's Uv 1 1 irrigation _:TXApprox. Depth I 1 Eastern Sur% a Seal Installed by /� /�iU�/.t' ��.� Repair Work Done L7 Type of Pump - H.P. Z. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material {top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION i I DESTRUCTION € I (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 ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines - Total length/size FILTER BED ❑ Distance to nearest: Well 'Foundation Property Line E SEEPAGE PITS 1 1 Depth Size Number SUMPS L) 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. 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 shalt 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,l shall employ persons subject to workman's compensa- tion laws of California." The applicant or I requ' p9ctions. Complete drawing on re ers ida, / p Signed X Title: _ Date: AEr U FOP DEPARTMENT USE ONLY r_ -7 Application Accepted by Date " l Area ! Pit or Grout Inspection .b date ^3 Final Inspection by Z2!74V_ Date Z, L- Additional Comments: ❑ Stk 466-6781 El Lodr 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 IFEE NFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'NO. -b ♦ EH 13.24 1 pEV.1/851 7 r I q� EH 14-2944 0 f