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APPLICATION FOR PERMIT '. SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 'f'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. Job Address �t��/� __.r7' _ CityIL� Lot Size PM Owner's Name I Address Phone x. g Contractor + Address License No,�3 U /C,�Phone TYPE OF ELL/PUMP: NEW WELL ❑ WELL REPLACEMENT LlDESTRUCTION C1 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 4INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i ❑ Industrial ❑ Open Bottom EI Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack El Tracy Type of Casing Specifications' 1 I" Public ❑ Other F1 Delta Depth of Grout Seal Type of Grout T I I Irrigation --Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Weil Diameter Sealing Material (top 50'1 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION l I DESTRUCTION (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 SEEPAGE PITS i I Depth Size Number SUMPS D 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 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 emptoy persons subject to workman's compensa- tion laws of California." The appPntst c for all re d -slec +tions. Complete drawing on reverse e. �a ' Signed Title: � ilil Date: FOR DEPARTMENT USE ONLY Ar p I Application Accepted by Date U Area Pit or Grout Inspec' y Date Final Inspection 6y Dat C ` r Additional Comments. ❑ Stk 466-6781 ❑ odi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1501 E. Hazelton Ave.,',P,O. Box 2009, Stk., CA 95201 ,JF FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. t.Eii 13-24 1REV.ti H INFO 51 lISWI EH 14-28 w