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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 .YEAR FROM DATE ISSUED. r o. _ t. (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District fora 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. .,. i7S 3 :iTalsf: `� _ Vii_ � t Job3 citys Lot Size x ddress PM Owner's NameT ° Pocoi _ Address Phone T Contractor's Name i-1'tzicense No. __ ___ _ __ _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 PRi78LEM ARTA CONSTRUCTION SPECIFICATIONS,t ❑ 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—0-.Eastern -..---.Surface-Seal-Installed-bye Repair Work Done s ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter ? Sealing Material(top!50')._ f Depth Filler Material( below 501" 9 TYPE OF SEPTIC WORK: NEW INSTALLATION PAIWADDITION 0.--,DESTRUCTION C1 (No septicsystempermitted if public sewer is ,� I I' t 3 ) - ! t available within 200 feet.) Installation will serve:. Residence_ Commercial_ Other sl Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth d '� SEPTIC TANK ❑ Type/Mfg Capacity ( No. Compartments PKG. TREATMENT PLT. ❑ k I Method of Disposal 'Distance to nearest: Well 4 Foundation Property Line LEACHING LINE &L--Mo. & Length of lines —^ �S fi'+�?e Total length/size Do9 FILTER BED ❑ Distance to nearest: Well r ` Foundation Property Line SEEPAGE PITS L3�pth Sizeumber`�"re�. SUMPS r * ❑ Distance to nearest: Well Foundation Property Line_ D �. DISPOSAL PONDS E❑ �-+- i hereby certify that I have prepared this application and that the work wili 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."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 la f California."° "e �' ^�' t The applican u call o tfi�uired ct. . C mplate drawing on verse si . - A e Signed Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by I Date .� Area 0� Pit-or Grout Inspection by Date62 Final Inspection by pate R JT'1 f: I . �W ., dditional Comments: F' -- AStk 4665,101111- -❑ odi 368-3621 ❑ Manteca 823-71_ q ❑I Tracy -835-6385 1 Applicant- Return all copies to: Environmental Health Permit/Service's 1601 E. Hazelton Ave:, P.O. Box 2009,Stk�CA 95201 TINFp CK AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY Y IJATE PERMIT"NO. +EH 1324{REV.1{1193} EH 14-28 .