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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL i ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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. +•)�••� r Joh Address1 �j !/ " __ i__✓_ City Lot Size 5 / PM Owner's Name Address 1 , 01 Phone Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 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 1-1 Public F Other n Delta Depth of Grout Seal �. Type of Grout Ct}� I I Irrigation ___Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _ ^\ Weil Destruction ❑ Well Diameter Sealing Material (top 50') t I Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I ) REPAIR/ADDITION I I DESTRUCTIO (No septic system permitted if public sewer is F. available within 200 feet.) W Installation will serve: Residence F' Commercial— Other Number of living units: __L Number of bedrooms ` Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg C +� C acity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: ' Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line _ DISPOSAL PONDS 0 k 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 nol� 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 perform a of the work for which this permit is issued, I shall employ ersons subject to workman's compensa- tion om ensa-- '� Y Pe P P Y P 1 p tion laws of California." The applicant must ca r all i d ins Complete drawing on reverse side. /� Signed Title /�% .,, Date: l&— FOR 7� FOR DEPARTMENT USE ONLY Application Accepted by _ Data l � I�` I Area k Pit or Grout Inspection by Date. Final Inspection byDate ri Additional Comments: M 1-e S- a W_ C_L_' c _ ❑ Stk 466-6791 ❑ Lai 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 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 CK RECEIVED BY DATE PERMIT'NO. INFO �7 pp---- SHEH 3.24 rryy + EH 14-261REV. lq e, C} ` <�