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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone Q091 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED IComplete 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. 18&2 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. 9(Job Address 3 3Y r City 343 Lot Size 41�-� �" PM `�, J �,• � _a� Owner's Name �/'� Address ✓ ��""� Phone r Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT El DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i 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 y: l`l Public ❑ Other Ll Delta Depth of Grout Seal Type of Grout I I Irrigation __-Approx. Depth i I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION X DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other *-Number of living.uniis: �Number of bedrooms Character of soil to a depth of 3 feet: Water table depth 1 SEPTIC TANK LlType/Mfg Capacity No. Compartments 4 PKG. TREATMENT PLT. 11Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total liength/size Q FILTER BED ❑ Distance to nearest: Well�0--t_2 Foundation ��ta�� Property Line dd SEEPAGE PITS 11 Depth Size T Number f SUMPS ❑ Distance to nearest: Well Foundation Property Line 1 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 f rules and regulations of the San Joaquin Local Health DF-strict. 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, 1 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 rtlust call for all r uired i o . Complete drawing on reve se side. Signe Title: 2� Date: FOR,DEPARTMENT USE ONLY r �y Application Accepted by Date Area Pit or Grout Inspection by�,/� Date Final Inspection b�y Date {7 f� /r Additional Comments: l Yl��" `d 4j)1 t� "_.. ❑ 5tk 466-6781 ffLo i 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 INFO AMOUNryT�DUE AMOUNT REMITTED �jC SR RECEIVED BY DATE PERMIT'NO. r.EH 1324IREV.iiHs) 3O� C / r� ( 3 �7 EH t4-26