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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ` 1601 E. HAZEL T ON AVE:, STOCKTON, CA l ; Telephone (209) 466-6781 r ` PERMIT EXPIRES V 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. y� Job Address _ A City /r' Lot Size PM Al a-� ,f e- �6 �l��d r Owner's Name � J Address Phone Contractor Address License No. Phone C 8 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION L. PUMP INSTALLATION ❑ SYSTEM REPAIR' ❑ OTHER ❑ DISTANCE TO NEARESIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATI AGRICULTURE WELL OTHER INE LIMPS INTENDED USE TYPE OF WELL PROB A CONST SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca ia. II Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel'Pack acy Type, Casing Spezifications +� FI Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout -- I Irrigation _..Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Do Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material Itop 50') . Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION l 1 DESTRUCTION I (No septic system permitted if public sewer is vailable 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 Cl 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 shalt 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 all for all required!,jnspections. Complete drawing on reverse side. Signed - Title: t Date: 4 I�P 7 FOR.DEPARTMENT,USE ONLY 7 �7 Application Accepted by Date' L Area t/0' Pit or Grout Inspection mob/ �y Date Final Inspection b Date Additional Comments- 711-101,7 7 _101 ❑ Stk 466-6781 ❑ Lo r 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 INFO AMOUNT DUE AMOUNT REMITTED K H RECEIVED BY DATE (PERMIT'NO. + EH 13-24[REV.riK5) �� .rQ �7' �' �/�,)0f EH 14-2a �y,