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- APPLICATION.FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA / I 'Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED .,, �l (Complete in Triplicate), ; f 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 D'1+strict. it t / ll�C� � f�J 4a' { • •{ yam _ ', ' .fob Address � � i Cit Lat Size �PM li l� Owner's Name Address j6t Phone i E, I Contractor � ? Address License No. Phone TYPE OF WELL/PUM NEW'WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR O OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES N. DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS iI 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 {y Specifications ❑ Public ❑ .Other ❑ Delia Depth of Grout Seal .i_ Type of Grout ❑ Irrigation y Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type'of Pump H.P. State.Work Done Well Destruction ❑ Well Diameter Sealing'Material Itop 50'1 Depth Filler Material {Below 50')-.--- TYPE 0'1_TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIO Wo septic system permitted if public sewer is [[}} vailable•within 200 feet.) Installation will.serve: Residence— Commercial Other Number of living units: 'I Number of bedrooms r � Characrter of soil to a depth.of 3 feet: .. ' Water table depth SEPTIC TANK ElType /Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ ° t Method of Disposal Distance to nearest: Well Foundationi ':Property Line ; j LEACHING LINE ❑ No�& L•ength of lines f a Total length/size FILTER BED ❑ Distance to nearest: Well Foundation - - Property Line 9V SEEPAGE PITS ❑, Depth -S.ize t Number SUMPS r 0 ;,Distance to-nearest:-�•-.-.-Well--- �r — Foundation Property Line DISPOSAL PONDS E] fes # 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, and rules and regulations of the San Joaquin Local Health District. _a 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'rs 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 t all for all required inspections. Complete drawing on reverse side. ` / Signed X J Title: Date: l\ Y FOR DEPARTMENT USE ONLY Application Accepted by Date '�' Area O OR or Groutlnspection by Date Final Inspection by Date Additional Comments f v Q ❑ Stk 466.6781 ❑ Lad 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 AMOUyNT DUE r AMOUNT REMITTED CASH RECEIVED BY DATE PERMiT•ND. + EH 13-'24(REV.Ids 5) . ' �' 1k 1 :. 1 EH 14-28 1. I E�30 ? �0_t