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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEILTON 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. �, �j Job Address 33C� ' '' , �`� v City [ Lot Size�� PM a� r It Owner's Namet' Address (� ^7 +� one { V / 7 J Z z� Phone_ �'SI�� Contracto Address . , License No. 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 PITS/SUMPS INTENDED USE t- _TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS { ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing f ❑ Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications M Public I.1 Other Cl Delta Depth of Grout Seal Type of Grout ___L_ I Irrigation --Approx. Depth i I Eastern Surface Seal Installed by Repair Work Donee ❑I Type of Pump H.P. State Work Done F Well Destruction i� Welt,Diameter Sealing Material )top 50'1 Depth ler Material (Below 501 TYPE OF SEPTIC WORK:' NEW INSTALLATION I 1EPAIR DDITION DESTRUCTION I I INo septic system permitted if public sewer is { available within 200 feet.) Installation will serve: Residence= Commercial T Other t Number of living units: _Z_ Number of e rooms 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 neaiest: Well Foundation Property Line s� f SEEPAGE PITS Depth Size Number SUMPS L3 Distance to nearest: Well r o,__ Foundation /,0 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 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." The applicant m call for all fired ' spections. Complete drawing on reverse sid Q Signed X Title: V` Date:Is Q u _ FOR DEPARTMENT USE ONLY Application Accepted by Date � --tSi Area or Grout Inspection by Date Final Inspection byfZ2Data Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 CI Manteca 823-7144 ❑ Tracy 835-6385 Applicant . Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 N f FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. ♦.EH t3-24{REV.i/x5) EH 1428 INFO �