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q /Q APPLICATION FOR PERMIT -1 ` ` t SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON 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. r S Job Address City Lot Size PM Owner's Name(-4V, `w t ss Phone Contractor ddres � � License N Phone Z TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK EWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION —IGWeULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLE AREA CONSTRUCTION SPECIFICATIONS ', ❑ Industrial ❑ Open Bottom ❑ Man ca Dia. of Well Excavation Dia. of Well Casing El Domestic/Private ❑ Gravel Pack El Tr Type of Casing Specifications MPublic F1 Other 171D to Depth of Grout Seal Type of Grout I I Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: fIEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I (No septic system permitted if public sewer is available within 200 feet Installation will serve: Residence_ Commercial_ Other t Number of living units: Number of bedrooms- Character 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 Ll 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 Di1trict. 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 ust call foroal6tecluired ins ctions. Complete drawing on reverse side. Signed X Title: �(,�j�t?./L '` Date: FOR DEPARTMENT USE ONLY Application Accepted by Date "u �� Area p Pit or Grout Inspection by ate Final Inspection by _ Date Zak U Additional Comments: ` ❑ Stk 466-6781 ❑iodIF 369-3621' ❑ 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 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT-NO. INFO CASH +.EH13-24(REV.1i85) EH 14-28 k3 0 1