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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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 welllpump and the Rules and Regulations of the San Joaquin Local Health District.' y�� /�36 C ` Job AddresMCD 1 City 1[\C>W��' t Lat Size _ �`"�'' -- PM _/1? Owner's NaAddressIM PhoneContractorct Address License No. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i 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 171 Tracy Type of Casing M1 Specifications M Public ❑ Other f �❑ Delta Depth of Grout Seal f Type of Grout —. I I Irrigation _.-Approx.'Depth I 1 Eastern Surface Seal-Installed Repair Work Done ❑ Type of Pump H.P. t "� State Work-Done_ \ Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material IBelow 501 . TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I.1 DESTRUCTION I I'-(No septic system permitted if public sewer is j r `available within 200 feet.) y Installation will serve: Residence_ Commercial_ Other i Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth- -~ SEPTIC TANK ❑ Type/Mfg Capacity mpartments PKG. TREATMENT PLT. ❑ _ Method of Disposal Distance to nearest: Well ndation Property Line LEACHING LINE ❑ No. & Length ees f d Total length/size FILTER BED ❑ Di a to nearest: Well Foundation Property Line ;SEEPAGE Pi l I Depth Size _ Number Cl Distance to nearest: Well Foundation Property Line POSAL 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. !'` i , ,,, e . . Home owner or licensed agent's signature certifies tate following:-1 certify that'in the performance ofthework 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." The applicant m call fo II re uired inspecti s. Complete drawing on reverse side. Signed X Title: � � -- Date: FOR DEPARTMENT USE ONLY ,iii / Application Accepted by Date �� Area ` Pit or Grout Inspection by Date Final Inspection by c Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 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 RECEIVED BY DATE PERMIT NO. INFO 7 CA�(SH �.EH 1124 IREV.1 i R 5] � - ! 1 lyn?� y I s (J�y��( 4V 36 1-1 11 EH 14-2a