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yJ APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ;i 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �I (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. I� Job Address fL7 City ize PM ! / I Owner's Nam Address Phone r' I Contractor Address License No. Phone TYPE OF WELL/PU P: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD-_ PROP. 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 ❑ Graver Pack ❑ Tracy Type of Casing Specifications F] Public ❑ Other n Delta Depth of Grout Seal Type of Grout 1 1 Irrigation _IIApprox. Depth I I Eastern Surface Seal Installed by _ V Repair Work Done L7 Type of Pump H.P. State Work Done _ \�, Well Destruction ❑ Well-Diameter Sealing Material (top 50'1 �I Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIRIADDITION I I DESTRUCTION?C INo septic system permitted if public sewer is II available within 200 feet) Installation will serve: Residence 4— Commercial_ Other 0 Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg �o. Compartments PKG. TREATMENT PLT. ❑ h IVI I I Upffit ethod of Disposal Distance to nearest: li Well Foundation Pr party Line Perrn U have. EXE�Ired wW� LEACHING LINE ❑ No. & Length of linesI TJi9 ldsize FILTER BED El Distance to nearest: elft Founds n Prpperty Line Aai Min DI by nvironmL SEEPAGE PITS 1 1 Depth Size Number SUMPS L-] Distance to nearest: Well Foundation Property Line 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 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 'nspections. Complete drawing on reverse side. Signed Xc;-41.6 Title: Date: II FOR DEPARTMENT USE ONLY Application Accepted by II Date , Z 1 Area 7-11 Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ L 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 I; IEEE JAMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PEERMIT'NO. r.EH 13-24(REV.I?K5) EH 14-28 f JJ !I