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APPLICATION FOR PERMIT • '` SAN JOAQUIN LOCAL HEALTH DISTRICT N� 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 Cn►^�+ 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. r: �' Job Address - `~ City-��1L Lot 5izeJ ! "{� PM Owner's Name ��r Address- - 1� Phone '`% sir" - v Contractor C 4p � Address "'�"— License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑. PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. P. LINE FOUNDATION AGRICULTURE WELL 0 LL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONS ION SPEGFICATIONS ❑ Industrial ❑ Open Bottom ,•❑ Manteca ia. of Well Excavation Dia. of.Well Casing Q Domestic/Private ❑ Gravel Pack r ❑ T Type of Casing Specifications Fl Public f7 OEher Delta Depth of Grout Seal Type of Grout ' Ill:lingation _..Ap epth. I i Eastern Surface Seal Installed by _ Repair Work Done ❑ of Pump H.P. State Work Done Well Destructio Well Dian eter Sealing Material (top 50') Depth Filler Material (Below..50') - TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIRIADDITION I IY DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial —1 Other 1 } f . a Number of living units: Number of bedrooms f Character f soil to a depth of 3 feet: Water table depth J\ 'SEPTIC TANK ❑ � Type/Mfg Capacity No. Compartments PKG. TREA rMENT PLT, ❑ ! f Method of Disposal ^•---- '°'� Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED' ' 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I 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 follow "I c y1 hat in he-performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California.' tt The applicant must -11)or all r ` uired inspections. Complete drawing on reverse side. Signed 1 Title: ,r rr �1r G�' 1 Date: - Ir� �` �*-•' OR DEPARTMENT USE ONLY {Q[� �' Application Accepted by Date —6 -CJ Area Pit or Grout Inspection by Da;s Final Inspection by Date Additional Comments: 4 11Stk 466-6781 ❑ i =3621 ❑ Manteca 823-7104 ❑ Tracy 836-6385 I Applicant- Return all copies to:�knvironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE INFO OUNT DUE AMOUNT REMITTED GASH RECEIVED BY DATE PERMIT NO. ♦.EH1 3-241REV.r/H5) � OJr/ EH 1426 f� (�(1 1