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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT [�- 1601 E. HAZEL T ON AVE., STOCKTON, CA I 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 1 Job Address A /3� �` Cr��`Ltt�l r� - City Lot Size 'v tO eS PM Owner's Name d a / h L Address �O C �� idl— Phone '�G 0 Contractor's Name C__4c-_� License No. - Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ DISPOSAL FLD. PROP_ LINE FOUNDATION AGRICULTURE-WELL OTHER WELL t PITS/SUMPS .� INTENDED USE TYPE OF WELL PROBLEM AREA ,CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy r -Type of:Casing Specifications ❑ Public ❑ Other ❑ Delta Depth Of Grout Seal Type of Grout Q ❑ Irrigation ---Approx. Depth ❑ Eastern ` r.Surface_Seal Installed by Repair Work Done ❑ Type of Pump H.PState Work Done (i\ Well Destruction ❑ Well Diameter Sealing Material {tap Depth Filler Material (Below 50') -- - TYPE OF SEPTIC WORK: NEW INSTALLATION V REPAIR/ADDITION ❑ ' DESTRUCTION ❑ (No septic system permitted if public sewer is / available within 200 feet.) Installation will serve: Residence ✓ Commercial_ Other i Number of living units: Number of bedrooms�_ •� � Character of soil to a depth of 3 feet: Water table depthRk -" SEPTIC TANK 2" Type/Mfg a Capacity Na. Compartments + PKG. TREATMENT.PLT. ❑ ` u Method of Disposal Distance to nearest: Well ICAO Foundation ;!S Property Line %07� i LEACHING LINE No. & Length of lines 3 'yd Total length/size" i FILTER BED ❑ Distance to nearest: Well /sb Foundation Property Line ro .r SEEPAGE PITS Qr Depth 29-' ._Size 3 3 Number � SUMPS ❑ Distance to nearest: Well rNQ Foundation /0 f Property Line /D a 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 +{I employ any person in such manner as to become subject to workman's compensation laws of California." Contractoes 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 applicantm t call for all equired inspections. Complete drawing on re rse side. Signed TiU@: Date: /� POR DE ARTMENT USE ONLY Application Accepted by zln2 Date Area ` Pit or Grout Inspection by ry -Y Date Final Inspection b Date Additional Comments: ❑ Stk 466-6781 06odi 369.3621 ❑ Manteca 823-7104 ❑ Tracy 835.6385 Applicant- Return all opies to: Environmental Health Permit/Services 1.601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTEDRECEIVED BY DATE PERMIT'N0. ' INFO [ ]CASH �l + EH 1324{REV.10/831 EH 1126 3