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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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. Job Address 1 City of Size PM Owner's NameAddress Phone Contractor's Name `� ��C.License No. L-kCN 0 S� Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR L7 OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing r�rn ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications U1 ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ 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 50') TYPE OF SEPTIC WORK: NEW INSTALLATION X REPAIR/ADDITION El DESTRUCTION X (No septic system permitted if public sewer is available within 200 feet.) v( Installation will serve: Residence_ Commercial Y Other , Number of living units:. Number of bedrooms Character of soil to a depth of 3 feet: Water table depth lzskokkk b� SEPTIC TANK X W Type/Mfg Capacltyl`&,X-� No. Compartments PKG. TREATMENT PLT. ❑ ,s. Method of Disposal /,� Distance to nearest: Well Foundation-�- ) Property Line S_ LEACHING LINE ❑ No. & Length of lines Total length/size I 31 W FILTER BED Distance to nearest: Well 1 Foundation_�� Property Line�� SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ 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 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, !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 la California." The ap icant usII for all 16tWired inspectAs. Complete drawing on reverse side. SignedTitle: -T _ Date: FOR DEPARTMENT USE ONLY Application Acc pted by _,� _ Date ``/-�•3 �'z Area l � � &0 Inspection by Date Fina! Inspection byqLjQ_-4— Data Additional Comments: ❑ Stk 466-6781 ❑ L i 369-3621 ❑ Manteca W7-7104 ❑ Tracy 8351385j( , � X Applicant- Retum all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., C 9520( `yG ' FEE AMOUNT DUE AMOUNT REMITTEDftli RECEIVED BYINFO DATE PERMIT"NO. EH 1324(REV.1DIffi) �� c� am-- �� i:L:,—Jl =t.3 EH 14-26 `