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�k APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE I ON AVE., STOCKTON, CA Telephone 12091 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) • Application is'he+eby made to the San Joaquin Local Health District for a permit to construct and/of 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. . + Joh Address I L Z City of Size PM r Owner's Name Phone Address _. - ' Contractor r "'"`"' Address icense No.0-59e -Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACWMENT ❑ DESTRUCTION ❑ I i INSTALL.A�T-UR ❑ YSTEM REPAIR - THER PUMP ❑ ° DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES,_% DISPOSAL FLD. PROP. LI FOUNDATION AG`Ff1Cl LTUREL'WELL 3 OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom 11 Manteca Dia. of Well Excavation Dia. of Well using t El Domestic/Private ID Gravel Pack ❑ Tracy Type of Casing Specifications - il Public ❑ Other 17i Delta Depth of Grout Seal Type of Grouk t I I Irrigation —:Approx. Depth L I Eastern Surface Seal Installed by - Repair Work Done ❑ Type�of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 `J Depth Filler_Material (Below 50') . TYPE OF SEPTIC WORK: NEW INSTALLATION —REPAIR/ADDITION l 1 DESTRUCTION f I (No septic system permitted if public sewer is W. available within 200 feet.) Installation will serve: Residence A— Com:'. t I �. Number of living units: [ �� Number �iGharacierrof soil to,a depth of 3 feet'1� Water table depth rI1 1 SE"" -��TIC TANK ~0 Type/Mig Capacity / b Na. fits PKG.TREATMENTLT. ❑ ' "� , Method of Disposal "x` Distad e to nearest: Well .��a Foundation ... Property•Line�MA �4- LEACHING LINE I)j No:,&•Length of lines �� Total length/size FILTER BED { 1 ❑ Distance to nearest: Well Z Foundation / Property Line' s SEEPAGE_PITS ( I DF pth Size Number , SUMPS Cl Distance to nearest: Well Foundation f•i�- Property Line DISPOSAL PONDS- _ ❑ ��I �f7Jr ►,-� Q I hereby certify!that'( have prepared this application and that thew will be dorid'in accordance-wig th San Joaquin county ordin nces, state laws, and I i rules and regull)ns 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 perrrjit 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 r certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to orkrnaks compensa- tion laws of California." IM i The applicant m st c Il for a! req 'red i ctioils. Complete drawing on reverse side. r1 Signed Title: _^ Date: I� FOR DEPARTMENT USE ONLY 1 I i Application Accepted by -- Date Area I Pit or Grout Inspection by ' Date ~ Final inspection by - Date IrMf Additional Comments: El Stk 466-6781 1❑ 1661 369-3621 ❑ Ma Ca 623-7104 © Tracy 835 5 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95261 r FEECKO AMOUNT DUE' AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO `4 +.EH13-24(REV.i i K 5) 6 - -.;� EH 14-28 111 fffv f J f l/