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rn s APPLICATION FOR PERMIT lA� LOCAL HEALTH DISTRICT SAN JOAQUIN LO . 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1 ' I (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 'lIlI' ov City _ �=� Lot Size .:5-0 X'leo -- PM f - �Addressgo f27 Phone j Owner's Name 1/119 , Contractor !I' E Address License No. Phone I TYPE OF WELL/Pump,—: I NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TA SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION TUBE WELL PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM A NSTR ECIFICATIONS I ❑ Industrial E1.1 pen Bottom nteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑Gravel P ❑ Tracy Type of Casing ifications -. F] Public f]' er 171 Delta Depth of Grout Seal Type of ` I I Irrigation !�_Approx. Depth I I Eastern Surface Seal Installed by Repair Work ne ❑ Type of Pump H.P.- State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth„ Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION (I REPAIR/ADDITION LI DESTRUCTIONKI (No septic system permitted if public sewer is F vailable within 200 feet.) I Installation will server Residence_ Commercial_` Other f 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 k PKG. TREATMENT PLT. ❑ Method.of Disposal Distance to nearest: Well Foundation Property Line I LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Welt Foundation Property Line SEEPAGE PITS l 1 Depth Size Number - t SUMPS ❑� Distance to nearest: Well Foundation Property Line' DISPOSAL PONDS ❑1 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 s rules and regulations of the. an Joaquin Local Health District. Home owner or licensed agent's signature certifies the fallowing: "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 i ' 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 must for all required"inspections. Complete drawing on reverse side. r Signed X I Title: Date: J M� 1 FOR DEPARTMENT USE ONLY Application Accepted by Date s-g'� Area t , r Pit or Grout Inspection b �ii Date Final Inspection Dateb l Additional Comments: _ A ❑ Stk 466-6781 �&,402ey"odi369-3621 ❑ Manteca 823-7104 ❑ Tracy S-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 EEE AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT'NO. INFO ♦ EH 13.21 ltiEV.I !t 51 Vii` i � �°��(} J �. �'r �✓� �� EH 14-28 F