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• APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA f� �•, .. 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 witp San Joaquin County Ordinance No. 549 for sewage or No. 1662 for well/pump and the Rules nd Re Matioryns/of the San Joa�juin Local Health District. l 30 � ®O f(7�5�� l y� Job Address /�/ r City Lot Si e PM Owner's Name _ . �*� Address NT Phone Contractor Address �1� J/l __ License No.^ _ Phone TYPE OF WELL/PUMP: NEWWELTX WELL REPLACEMENT ❑ DESTRUCTION ❑ yy PUMP INSTALLATION � t SYSTEM REPAIR ❑ OTHER ❑ XV f O `..DISTANCE TO NEAREST: SEPTIC TANKs ._ SEWER LINES " D"ISPOSAL'FLD. •'' PROP. LINE �_ 0) } 9 AGRICULTURE WELL = OTHER WELL_,__ PITS/SUMPS I � Ili 1-_..._-__.— - INTENDED USE TYPE OF WELL PROBLEM AREA . CONSTRUCTION SPECIFICATIOM ❑ Industria! Open Bottom ❑ Manteca Dia_ of Well Excavation f Dia. of Well Casing 1-4 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing S 12LEL Specifications 83 kw/- -I-1 Public n Other Cl Delta Depth of Grout Seal -Type of Grout X— 1rrigation .-Approx. Depth &_�I"I Eastern Surface Seal Installed by Repair Work Done L1Type of Pump.1 V_E_ 5 H.P. 40 State Work Done Well Destruction ❑ Wel! Diameter Sealing Material (top 50') Depth'. IFiller Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I') REPAIR/ADDITION I I DESTRUCTION I 1 INo septic system permitted if public sewer is available-within 200 feet.) t 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. ❑ t Method of Disposal Distance to nearest: Well Foundation Property.Line t r. LEACHING LINE "❑t No. & Length of lines Total length/size , FILTER BED ❑ Distance'to nearest:" t Well gFoundation Property Line e +k SEEPAGE PITS 11 Depth Size Number ; SUMPS ❑ Distance to nearest: Well ' Foundation Property Line DISPOSAL PONDS ❑ 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." t The applicant I requir ions. Complete drawing on rev re side. Ufa Signed X 7zof ' Title: .!/�–C�` .ick✓. Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspe y Date Final Inspection by Date= I Additions! Comments: h� /��Z17- LJ 1❑ Stk 466-6781 ❑ Lod" 3b9-3621 ❑ 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 O I FEE AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'NO. INFO +.EH13-24(REV.tins) v EH 14-28 ' Set —g 1 i f ' e