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t - - a--- i APPLICATION FOR PERMIT I SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL i ON AVE., STOCKTON, CA 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 i 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 / T Ci Lot Size PM Owner's Na Address Pho 1 � Contractor Addre �_ E. �.f ��.. . icenseN,¢��Phone��__50 / TYPE OF WELL/PUMP: 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 PI PS i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFIC L1 Industrial ❑ Open Bottom El Manteca Dia. avation Dia. of Well Casing ` ❑ Domestic/Private ❑ Gravel Pack -❑ Trac Type�of Casing '^"" "'` Specifications ( /) (1 Public Cl Other Delta Depth of Grout Seal Type of Graut _. \1 I I Irrigation A Depth l I Eastern Surface Seal Installed by Repair Work Done pe of Pump H.P. State Work Done Well Destru ❑ Well Diameter Sealing Material (top 50'1 Depth Filler Material "low 501 a _ TYPE OF SEPTIC WORK: NEW INSTALLATION i I REPAIR/ADDITION I I 'DESTRUCTI TNo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms `;' Character of soil to a depth of 3 feet: Water table°depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments 11 PKG. TREATMENT PLT. ❑ + Method of Disposal hDistance to nearest: Well Foundation Pr6perty Line y LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation- Property Line SEEPAGE PITS I 1 Depth Size _ Number ' SUMPS ❑ 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 applican m st call for all required i pections. Complete drawing on 2!;,;r_1 da. Sign Title: Date: FO DEPART NT I15E ONLY Application Accepted by Date " 9 Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: " ❑ Stk 466-6781 ❑ Lod 369-3621 ❑.Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 20(X9, Stk., CA 95201 FEE INFO AMOUNT DUE A UNT REMITTED C K H RECEIVED BY ^^^--��PATE ^� PERMIT'NO. +.EH 13-241REV.t/n51 y✓ .O� /_� EH 14.26 �"' / [/U