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� Y APPLICATION FOR PERMIT t SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL i ON AVE.,,STOCKTON, CA Telephone (209) 466-6781 Yrs rat t:. PERMIT EXPIRES 1 YEAR .FROM DATE ISSUED (Complete in Triplicate)r I' Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. Thjs 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 / � . r �/. Y t City T " "' Lot Size /` J PM bi/l lam ` / L�/�/�G Address Owner's Name Phone J/J/f Contractor 4MUlt Address License,No. Phone TYPE OF WELL/PUMP: w NEW WELL ❑ WELL REPLACEMENT ❑, DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑r OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL'FLD F PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL j. 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 ❑ Public ❑ Other "' ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern —Surface-SeaLJnstall_ed_by - r Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') t Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is -4 available within 200 feet.) s Installation will serve: Residence Commercial— Other F I Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: - Water table depth SEPTIC TANK TypeFMfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ 1 Method of Disposal Distance to nearest:- Well I, Foundation Property Line 1 LEACHING LINE Q' No. & Length of lines Total length/size I FILTER BED ❑. Distance to nearest: Well }' Foundation Property Line f SEEPAGE PITS ❑ Depth Size �~ u 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 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." 11 1 The applicant must call for all r quired inspections. Complete drawing on reverse side. Signed Title: Date: ` FOR DEPARTMENT USE ONLY _ `Application Accepted by Date _ Araa Pit or Grout'lnspection Date FinalJnspection by Date Additional Commen . � �eL ��Stk 466-6781 ❑ Li: 36 M823 7104 �Tmcy�835-638i Applicant- Return all copies to: Environmental Health Permit/Services.1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMITNO. + EH124•(REV.t/x5) C C> EH 14,26 �3 I "1 _ r