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F APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT r 1601 E. HAZELTON AVE.,"STOCKTON, CA C? 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 Address f City -Lot"Size PM " 67 Owner's Name Address Phone Contractor Address License No. Phone TYPE OF WELL/PUMP: i ' NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ S�ELL - OTHER ❑ DISTANCE TO NEAREST: SEPTIC TAN SEWER LINESISPOSAL FLD. PROP. LINE [" FOUNDATION AGRICULTUTHER WELL PITS/SUMPS _ r INTENDED USE TYPE OF WELL OBLEIIA AR CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom. - ❑ to Dia. of Well Excavation Dia. of Well Casing T ❑ Domestic/Private b Gravel Pack ❑ Tr Type of Casing Specifications ❑ Public 171 Other' ` 4 eIt_ Depthsof Grout"S 6al' t Type of Grout ❑ Irrigation �!Approx. Depth ❑ 'Eastern rface Seal Installed b"y 1 Repair Work Done ❑ T e of Pum ) H.P; Yp p State Work pane Well Destruction ❑ Well Diameter 4 Sealing Materia! (top 501 r ' Depth 1 " Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑:. REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Others t Number of living units: i Number of bedrooms r rY �. Character of soil to a depth of 3 feet:.- s r "+ - -.t -- - i _ . -... Water table depth SEPTIC TANK ❑ Type/Mfg f Capacity No. Compartments ' PKG. TREATMENT PLT. ❑5 I� t r i + Method of Disposal - t Distance to nearest: 4 Well Foundation " Property Line LEACHING LINE`- ❑' No. Length of lines f ' . g r Total length/size + FILTER BED ❑ Distance to nearest:" Well" " -Foundation ;Property Line SEEPAGE PITS " ❑ Depth a Size Number + SUMPS ❑ Distance to nearest:"-w- Well Foundation Property Line 6 11 DISPOSAL PONDS ❑ ° v 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 must call for all required inspections. Complete drawing on reverse side. Signedr Title: Date: vi09 OR+ PARTMENT USE ONLY Application Accepted byDate Y � Area ` Pit or Grout Ins + pection'by Date Final Inspection by ate — —g 7E Additional Comments: 5 c Com, D Stk 466-6781 - ❑ 1_6dly,369-3621 ❑ MaWca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O.SBox MA*CA'CA 95201 ° INFO AMOUNT DUE' AMOUNT REMITTED tCK RECEIVED BY DATE PERM17 N0. y +"EH 13-241REV.I 85Y VU �" _ �. nay/ (X�7 ` i EH 14-26 3 .�_, t ,. ..