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m` 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 wail/pump and the Rules and Regulations o1 the San Joaquin f Local Health District. �,y lY City 4 Lot Size PM Job Addres.1t"-_ '006 's, .YV � /� I Owner's Nam LX✓'�� !� " Address S�y `J O Phone Contractor � Addless ��- `— _License No. Phone TYPE OF WELL/PUMP:. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ I I -DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS rINTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ElI.ndustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Wel! Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications r l'1 Public n Other F1 Delta Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth I 1 Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H,P. i State Work Dane _ Well Destruction ❑ Well Diameter Sealing Material {top 501 Depth Filler Material Melow 50.1 TYPE OF SEPTIC WORK: NEW INSTALLATION IT REPAIR1ADDITION I I DESTRUCTION Y (No septic,system permitted if public sewer is available within 200 feet.) Installation will serve: Residence �-,• Commercial_ Other r v 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 PKC. TREATMENT PLT. ❑ �w " " Method of Disposal , r } hV i Distance to nearest: Well Foundation °Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to dearest: Well Foundation Property Line �. SEEPAGE PITS f i Depth Size = Number SUMPS ❑ Distance to nearest: Well Foundation Property Line G' 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 applicantmust`call Jfor all r�eguired inspections. Complete drawing on.reverse side. Signed X i'4� 1�+'"`� Title: � _ Date: �L ` FOR DEPARTMENT USE ONLY Application Accepted by V Date VZ':.) Area 1� Pit or Grout Inspection by Date Final Inspection by _ date x Additional Comments: f Ql� �> ❑ Stk 466-6781 ❑ LA 369-3621 ❑ Manteca 823-7104 ❑ T acy 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 CK RECEIVED BY DATE I PERMIT-NO. INFO �p + EH 13.24 1REV.I/H 57 EH 14-26 e�