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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 f PERMIT EXPIRES 1YEAR FROM DATE ISSUED (Complete in Triplicate) I 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. 18&2 for weii/pump and the Rules and Regulations of the San Joaquin Local Health District. i Joh Address ?op City d Lot Size`-- PM Own96 er's Name Address�T�'�/ Phone _._� I Contractor C Address �? License No. 7 Phone F TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ f }] PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP, LINE F I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F1Industrial ElOpen Bottom ElManteca Dia. of Well Excavation _ Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications FI Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout — ` I 1 Irrigation _..App rox. Depth l 1 Eastern Surface Seal Installed by - j Repair Work Done ❑ Type of Pump H.P, State Work Done _ 'Well Destruction ❑ Well Diameter Sealing Material (top 50')*� Depth Filler Material (Below 501 -- TYPE OF SEPTIC WORK: NEW INSTALLATION te REPAIR/ADDITION l I DESTRUCTION l 1 (No septic system permitted if public sewer is li available within 200 feet.) Installation will serve: I Resi ence_ Commercial Other ?L} Number of living units# _ Number of ooms_,t Character of soil to'a depth of 3 feet: Water table depth ' SEPTIC TANK C�TypelMfg Capaci[y _ No. Compartments Q PKG. TREATMENT PLT7❑ Method of Disposal 6 I Distance to nearest: Well Foundation OZO Property Line LEACHING LINE L� nlo. & Length of lines f Total length/size FILTER BED r ❑ Distance to nearest: Weil/�•C1 Foundation Property Line I I SEEPAGE PITS &+--Depth .� Size Number i SUMPS ❑ Distance to nearest: Well /SDS r 4oun_dation_ +Property Line i DISPOSAL PONDS ❑ , I hereby certify that I hake prepared this application and that the work will be done in Accorda cert with San-Joaquin county ordinances, state laws, and\] .{rules and regulations of the San Joaquin Local Health District. 't `r � Home owner or licensediagent's signature certifies the following: "I certify that in the pefffce of the forrmanwork for which this permit is iss ed, I shall not .. . employ any person in such manner as to become subject to workman's compensation lAws of`C.alif_ or�nia`'�Cont�( tor s hlnngnr sub contracting signatur certifies the following: "{'certify that in the performance of the work for wAth t is permit s issued, I shall employ.per�ssub�ect to workman's compensa- tion laws of California." 1 The applicant must callfor all re�di tions. Complete drawing on.er erse side. Signed X��/ i Title: C:/ lai ilJ�/t ` Data: r' J"x FOR DEPARTMENT USE ONLY Application Accepted b Date 71 Area P. or Grout Inspection L V_�_—L Date /1q__TP117FinaI Inspection by ate ✓�� Additional Comments: ❑ Stk 466-6781 --l�l-L-odi-369.3621- E-Manteca--U-3 7.104—8Tracy-835=6365 Applicant- Return all copies to: Environmental Health Permit/Services�1601 _ Hazelton Aver"P`O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED H RECEIVED BY DATE PERMIT'NO. r INFO e�q +.EH 13-24{REY,i/w 51 EH 74-28 8 � '