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APPLICATION FOR PERMIT PAYM-ENT SAN JOAQUIN LOCAL HEALTH DISTRICT RECEIVED 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 X I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED .ENVIRONMENTAL HEALTH (Complete in Triplicate) PERMIT�SER Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This apol�� eSn 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 Dist t.52 Qf Job Address [ � Q Cityr r Lot Size PM Owner's Name \-� Address Phone "6 ContractorJ& * Address/17-1-V II"-irlQ I'.64tl- License No.%i!T� Phone -`tQtri TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR❑ OTHER CI, 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 IL Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F1 Public ❑ Other 1-1 Delta Depth.of Grout Seal Type of Grout I I Irrigation --Approx. Depth I I Eastern Surface Seal Installed by `� e ,A*PM Work Done ll Type of Pump -�- H.P.I— State Work Done QIS��+'t� k,d Well Destruction ❑ Well Diameter Sealing Material (top 501 !!��- Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available 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 ❑ 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, 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 ust c all required inspections. Complete drawing onjilyerse/side. Signed X Title: _ /�Jal�✓ Date: 10, FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by CKe Date Additional Comments Nil ��IAU ❑ Stk 466-6781 ❑ lZodi 369-3621 &1 ❑ Manteca 823-7104 f3 Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO CASH +,EH 13-241REV.tins) EH 14-2a _ ✓✓ YJ v/iI �/ /