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cb { APPLICATION FOR PERMIT I SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES T YEAR FROM DATE ISSUED I �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. -Il SI '. Job Address >g&4! 1 _4 ,1]6, City Lot Size PM Owner's Name1 � Address a Phone66� 1 E c� Contractor j�. Address � V License No. Phone TYPE OF WELL- PUMP: - NEW WELL ❑ WELL„REP.LACEMENT.❑� DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ u w OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. t P Y_ FOUNDATION AGRICULTURE WELL OTHE PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA—CONS - N,SPECI14GATIONS ❑ Industrial ❑ Open Bottom Cl Manteca ia. of Well Excavation t Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack acv 3 Type of Casing Specifications fi F1 Public ❑ Other C1 Delta Depth of Grout Seal t Type of Grout I I Irrigation _IiApprox. Depth { I Eastern Surface Seal Installed by , Repair Work ❑ Type of Pump H.P. State,Work Done estruction ❑ Weil hDiameter g Sealing Material (top 50') Depth Filler Material(Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION I //—DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial Other .A Number of living units: �� . Number of bedrooms Character of soil to a ept of 3 feet: ` ' Water table depth SEPTIC TANK Type/Mfg "Capacity No. Compartments , n PKG. TREATMENT PLT. ❑ Method o1 Disposal bistance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines i Total length/size 1 FILTER BED ❑ Distance to nearest: Well Foundation Property Line ` I SEEPAGE PITS I I Depth Size Number .• SUMPS L7 Distance to nearest: Well Foundation i Property Line 1 DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and tl�at 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. s 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." Contractors 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." T licant must c f r all Ie uire ins ions. Comp!te-drawmg-on-reverse ---,---�--�- Signed X Title:4o�lm Date: i FOR DEPARTMENT USE ONLY IjC31471 I Application Accepted b Date ` Area Pit or Grout Inspection I Date Final Inspection by Date ! Additional Comments: ❑ Stk 466-6781 ❑ Lo& 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to, Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2 Stk., CA 95201 I IFEE NFO AMOUNT DUE AMOUNT REMITTED CK H RECEIVED BY DATE PERMIT'NO. 4 `� i EH 13-24 EH 14-26 IREV.I/x 51 U\.i 1 i41 . 1 c V v --