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APPLICATION FOR PERMIT I SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 'I 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. r jam' ,/� J 1/ ` ' /2— i � 1 r l Job Address 002- u t ✓i.. City Lot Size PM Owner's Nameh�Q�iJt' W Address �fl1 � Phone Contractor 4L Address License No. 3j. 2 Phone 4? TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. POOP. 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 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public C-} Other ❑ Delta Depth of Grout Seal Type of Grout r r I I Irrigation —. .Approx. Depth i I Eastern Surface Seal Installed by Repair Work Done E Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 F # I Depth Filler Material {Below 50'} TYPE OF SEPTIC WORK: NEW INSTALLATION [1 REPAIR/ADDITION V&STRUCTION E I (No septic system permitted if public sewer is Commercial available within 200 feet.) Installation will serve: Residence— Commercial�_-_ Other 4 y 3 . U Number of living units: A_ Number of be Character of soil to a depth of 3 feet: drooms~� Water table depth �# r <)SEPTIC TANK ❑ Type/Mfg Capacity - No. Compartments A° i PKG/TREATMENT PLT- ❑ ' Method of Disposal Vit/! Distance to nearest: Well .Foundation Property. Line id �ACHING LINE e A00"No. & Length of lines %` Total length/size j 1 i NUS ER BED,- ❑ Distance to nearest: Well Foundation Q f- -Property Line SEEPAGE PITS 111141"'Depth e Number . / SUMPS Cl ' Distance to nearest: �i/ell "i ,, b Foundation 0 Property Line_L s r DISPOSAL PONDS ❑ If r I hereby{certify that I have prepared this application and that the work wilt 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'foilowinbn"I certify that in the performance of the work for which this permit is issued, I shalt not r employ any person in such manner as to become subject to..workrnan'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." � I I " The applicant must call for alt quired inspections. Complete drawW-'64vgr'se side. 'Jit 1 t�f. �f Signed X !/ �R f Title: _�/��r. r Date: FOR DEPARTMENT USE ONLY f Application Accepted by Date Area I Z ' GP or Grout Inspection by Dae Final Inspection by Date Additional Comments: J 1 ❑ Stk 466-6781 ElLodi 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 ,''`'MOYNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO- r`� /�� j +.EFr13- IREV.1✓R51- � �. W �. [hJ I / X �. S. /p�' � EH11 �f !! V