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All/ 1c'Nel) t 01Y .� APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON 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 �j Job Address _/�Ct7 /�x-17` � R City i Lot Size PM q9-- z� Owner's Name Al AddressT Phone - , p �j Contractor Address �G License No. P � Phone 1 �� TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT 0 DESTRUCTION ❑ PUMP INSTALLATIONSYSTEM REPAIR D OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK �z SEWER LINES �� DISPOSAL FLO. PROP. LINE AW FOUNDATION AGRICULTURE WELL BOTHER WELL PITS/SUMPS ZZS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I A ❑ Industrial D Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing } �omesticlPrivate �L7Gravel Pack .LJ Tracy Type of Casing Specifications f'1 Public f_1 Other 1 Cl Delta Depth of Grout Seal �� Type of Grout I I Irrigation2�pproK, Depth l I Eastern Surface Seal Installed by � _ II Repair Work Done D Type of Pump -.-._ � H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 _ N TYPE OF SEPTIC WORK: NEW INSTALLATION 11 RFPAiR/ADDITION l I DESTRUCTION I 1 INo septic system permitted if public sewer is available within 200 feet.l i 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 D 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 ❑ Distancetonearest: Well Foundation Property Line SEEPAGE PITS I I Depth j Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL-PONDS D I 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, an 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,l shall employ persons subject to workman's compensa- tion laws of California." i' The applicant t l fqf II requi i ions. Complete drawing on levWso side. Signed X Title: Date: DEPARTMENT USE ONLYApplication Accepted by Date J AeAreaPit or Grout inspection by j!R I-?51 Final Inspectiog by C Date Ap_P-2W, Additional Comments: . v D Stk 466-6781 El Lor 369-362 - D anteca 1123-7104 ❑ Tracy 835-6385 I Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMfOUNT DUE AMOUNT REMITTED GASH CK RECEIVED BY DATEr/' PERMITNO. +.EH 13-24(REV.r/K5) EH 14-26