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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ,3 (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. A, } 0 Job Addres � Ci Lot Size PM e V I �� A13 Q"address Phori N �t0`74' �^ Owner's ^• ` �l Contrac Address ��111�1�+�T1License Nb- Phone .5 ,:5 `r TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ I 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 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 �( Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout rrigation ----Approx. D stern Surface Seal Installed by e Repair Work Done ❑ Type of Pump_ H.P. �1�� State Work Done Well Destruction-©Well Diameter, T Seali6gtMaterial (top 501 J ! Depth"' Material (Below 50') TYPE_ OF SEPTIC ORK: NEW INSTALLATION ❑ REPAIR/WDDITION DESTRUCTION (No septic system permitted if public sewer is 1 WLl Within 200.feet.) �. Installation will serve: Residence b Commercial_ .Other rt Number of living units: r,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 _Cb " Distance to nearest: Well Foundation Property Line j s LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS-J ❑ Distance to nearest: Well Foundation Property Line P. r DISPOSAL PONDS ❑ C 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, 1 shah-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•tie fo wingr"I certify that in the performance of he work for which this permit is issued, I shall employ persons subject to workman's coinpensa- tion laws of a forma." i The applic t stcall for I r q ire ins c' ns. Co pl to drawing on rse side. Signed Title: Date: FOR DEPARTMENT USE ONLY f _ Application Accepted by Date g�Area t F Pit or Grout Inspection by Date Final Inspection by ` Date 15 I Additional Comments: 5. I–� e ❑ Stk 466-6781* ❑ L 369-3621 El Manteca 823-7104 if Tracy 835-6385 R 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 CK RECEIVED BY DATE PERMIT-No, + EH EH 13-24 24 IREV.t/a 5)