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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209) 4.66-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (Complete in Triplicate) Application is heteby 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 City Lot Size PM _ Owner's Name ��firess ,' Phone rr / 1 Contractor dress License Nol Phone Yvq4f TYPE OF WELL/P MP: NEW LL ❑ WELL REPLACEMENT ❑ 1 TRUCTIO ❑ 1 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE e FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS Y INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private- D Gravel Pack ❑ Tracy Type of Casing Specifications l'} Public F} Other ❑.Delta- Depth of Grout.Seal Type of Grout I I Irrigation _--Approx. Depth- l I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _ I: i Well Destruction ❑ ' Well Diameter Sealing Material (top 50'1 ' . 1. Depth Filler Material (B 10 ') Y TYPE OF SEPTIC WORK: NEW INSTALLATION Cl REPAIR/ADDITION -I DESTRUCTION l I INo septic system permitted if public sewer is ; available within 200 feet.) Installation will serve: Residence commercial— ther 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',❑ ` ,� Disposal Ly' Method of his i t Distance to nearest-"'—Well ' "Foundation Property Line 1 t ell LEACHING LINE ❑' No. & Length of lines ti Total length/size # t FILTER BED ❑. Distance to nearest: Well� Foundation h� Property Line SEEPAGE PITS I I Depth Size ° Number SUMPS LI Distance to nearest: Well Foundation f' '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 mut calLJw,,all requird ',n pections. Compla drawing o verse side. t ' Signed X Title: -- Date: �. OR DEPARTMENT USE ONLY Application Accepted byDate Area �. t af�7 II Pit or Grout Inspection-bye ! at �`" Final Inspe do by Date . Additional Comments: ❑ Stk 466-6781 ❑toji .369 3621 n Manteca -7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 85201 FEE INFO AMOUNT DUE A REMITTED CASH RECEIVED BY DATE PERMIT'NO. 6 ♦ EH13 24(REV.rind EH 14 26 _ M