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,s �4 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA j 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. Job Address Lot Size PM Owner's Nam Address Contractor Addre � � Licenseco.*X/��Pho J TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ; DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFIC ❑ Industrial ❑ Open Bottom - ❑ Manteca Dia. of W atlon Dia- of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy pe of Casing Specifications FI Public (7 Other Depth of Grout Seal Type of Grout _ I I Irrigation pro I I Eastern Surface Seal Installed by Repair Work Done ❑ o Pump State Work Done_ Well Destr 11 Well Diameter Sealing Materiat.ltop 501 t Depth Filler Material (Below 5011 \\ TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I. DESTRUCTIOlNo septic system permitted it public sewer is v available within 204 feet.) �I Installation will serve:' Residence_ Commercial_ Other Number of living units: I Number of bedrooms Character of soil to a depth of 3 feet: ' Water table depth SEPTIC TANK ❑ Type/Mfg `� Capacity No. Compartments PKG, TREATMENT PLT. ❑ K Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE CI No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well 1 Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance tb 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 Joaquiri Local Health District. Home owner or licensed agent's signature certifies the following: "Ir certify that ih the pbffo(riiahce 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." 1. The applicant st call for all requir nspectione, complete drawing on (everp side_ Sign Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date � y fJ—Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 L i 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 CASH + EH 13-24(REV.rin5) �� . i� A, g-fs � EH 14-28