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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL i 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. ! y c �1 �.trQ• City Lot Size G� PM — Job -Address Owner's Nam(2) Address °t •; Phone -703 r< / /'� n Phone 3 z - 3I Gf Contractor's Name +�^� - License No. TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ -{ I PUMP INSTALLATION ❑ SYSTEM REPAIR' OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES t '; DISPOSAL FLD. PROP. LINE I FOUNDATION AGRICULTURE WELL r ' OTHER WELL PITS/SUMPS INTENDED USE ❑ Industrial ❑ Domestic/Private C1 Public i ❑ Irrigation Repair Work Done Al Well Destruction ❑ y TYPE OF WELL PROBLEM AREA CONSTKU(; I IUN twtt,im m 1 lv+d o ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ❑ Gravel Pack ❑ Tracy Type of Casing ❑ Other ❑ Delta Depth of Grout Seal ---Approx. Depth ❑ Eastern Surface Seal Installed by TV NR H.P. �~ State Work Done _ Type of Pump certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons Well Diameter : Sealing Material Itop 50'1 Depth )' Filler Material (Below 50') ' Dia. of Weil Casing Specifications Type of Grout t, TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No lsebpticvsf tem in 2C Installation will serve: ResidenceCommercial a Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK { ❑ Type/Mfg — PKG. TREATMENT PLT. ❑ ay.; feet.) Water table depth — Capacity No. Compartments . ! Distance to nearest: Well Foundation LEACHING LINE ❑ No. & Length of lines FILTER BED ❑ Distance to nearest: ,Well Method of Disposal - Property Line Total length/size— Foundation ength/sizeFoundation Property Line it public sewer is 9 SEEPAGE PITS ❑ Depth Size Number " Property Line _ SUMPS ❑ Distance to nearest: Well Foundation DISPOSAL PONDS ❑ that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and I hereby certify rules and regulations of the San Joaquin Local Health District. "I that in the performance of the work for which this permit is issued, I shall not Home owner or licensed agent's signature certifies the following: certify employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub contracting signature subject to workman's compensa- certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons tion laws of California." The applic list call for all required inspections. Complete drawing on reverse side. — gY Date: ��cr,ec Title:� �-�-� Signe �. t FOR DEPAR MENT USE ONLY U i Date Area Application Accepted by iU� ZS�Y Date L Pit or Grout Inspection by Date Final Inspection , Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 0 Tracy n"385 Health Permit/Sehrices 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 Applicant - Return all copies to: Environmental AMOUNT DUE ~ CK# RECEIVED BY AMOUNT REMITTED CASE{ DATE PERMIY'NO. INFO psi +EH13241REV.101831t S�Q, &v - EH 1426 - „s .a .,