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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (Complete in Triplicate) Application is.heieby 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. E Job Address u �/ Cit l of Size! M Owner's Name h AdI Address D �� Phonev/� Contractor �[/ Address i -tom License Na Pho +�l�� �- TYPE OF WELL/PUMP: NEW WELL Er WELL REPLACEMENT,❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ l DISTANCE TO NEAREST: SEPTIC TANK 14"eAl SEWER LINES DISPOSAL FLD. PROP. LINE '•, FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 1 r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI4N5 ❑ industrial .' pen Bottom ❑ Manteca Dia. of Well Excavatio Dia. of Well Casing �` J /Private""- '❑'Gravel Pack-� ❑ Tracy Type of Casing Specifications (7 Public% s n Other Cl Delta r of Depth ' p Gout Seal Type of Gr it I I Irrigation —'A-,.Approx. Dept Eastern Surface Seal Installed by Repair Work Done 0 Type of'Pump H.P. State Work Done'= Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth yFiller Material (Below 501 TYPE OF SEPTIC WORK: NEW-INSTALLATION Ia"REPAIR/ADDITION I I DESTRUCTION i I (No septic system permitted if public sewer is ` available within 200 feet.I Installation will serve: Residence— Commercial Other ti, s If Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth x SEPTIC TANK . ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE i ❑' No. &Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line 1 { SEEPAGE PITS I I Depth Size Number SUMPS 0 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ;❑ r 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 m call for all required inspections. ate drawing on revers ide. r Signed Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Pito ro nspection by Date �3 " Final Inspection by Date _ Additional Comments: h _ I�5 �' y 2 ' L7 Stk 466-6781 ❑ Loi 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 AMOUNT DUE AMOUNT REMITTED INFO CASH RECEIVED BY DATE PERMIT'NO. + EH 13-24IREV. /14 5) /0�� jP!S� ` —d;,?•Eli 14-2a (/