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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT _ r 1601 E. HAZEILTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED a. III: (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. Job Address ' Z City Lot Size J /4c- PM Q Owner's Name Address ! �—� Phone O Z Contractor's Name � License No. 3 O S ,2/ W Phone 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 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 ❑ Gravel Pack ❑ Tracy Type of Casing Specifications r ❑ Public Q Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION UKDESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence r./ Commercial_ Other Number of living units:.. Number o bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal f Distance to nearest: Well Foundation Property Line LEACHING LINE 0,"No. & Length of lines Total length/size o \ FILTER BED ❑ Distance to nearest: Weil�00 I Foundation 0io-2 _.— Property Line SEEPAGE PITS Depth _ �f Size Number 0= SUMPS ❑ Distance to nearest: Well 1D + Foundation 070' Property Line DISPOSAL PONDS ❑ 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 Sam 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."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." MI The applicant must call or ay required inspections. Complete drawing on reverse side. Q�/(�G� ( Signed Title: Date:�... A FOR DEPARTMENT USE ONLY c Application Accepted by Date J Area **-- Pit or Grout In pecti n by Date a 'Final Inspection by Date DAdditi� co °e Etr�s: -e r o • — f ❑ Stk 466.6761 Nodi 369-3621 ❑ Manteca 821-7104 ❑ Tracy Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. INFO _ + EH 13-24(REV.10183) EH 1420 • o