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APPLICATION FOR PERMIT tAN JOAQUIN LOCAL HEALTH DISTRI& 1601 E. HAZELTON 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. C m P, Ci/ )llpecr Size PM Job Address -}y� L M Qt}} 1 I Address Phone Owner's Name .��, -��l D / n ESQ tl License NoL�Phone U I . Contractor t�la1 L ('�/11`C`�Address 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 SPECIFICATIONS Dia. of Well Casing ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications ❑ Domestic/Private ❑ Gravel Pack ❑Tracy Type of Casing Type of Grout_ P Public ❑ Other ❑ Delta Depth of Grout Seal t I Irrigation —Approx. Depth I I Eastern 'Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth Filler Material IBelow 501 - TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION STRUCTION I I available within tin system permitted if public sewer is Installation will serve: Resi encsCommercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg C Capacityf�O No. Compartments PKG. TREATMENT PLT. ❑ P-'_L— C 01acr-6+E—; Method of Disposal vJ Distance to nearest: Well, Foundation Propertyline LEACHING LINE Lam. & Length of lines — Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line _ SEEPAGE PITS I I Depth Size Number SUMPS 0 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 e rules and regulations of the San Joaquin Local Health Di1trict. 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 personin such manner as to become subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature can s 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 a f California." The apptican t call all r uired i specti ns. Com a drawing verse si r Si ned Title: 9L� � �'r Date: 9 1` MFOR DEPARTMENT USE ONLY Application Accepted by 1�, 1 C ^ Date _� — Area Pit or Grout Inspection by Date Final Inspection by r Date �2� Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 8217104 ❑ 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 GASH RECEIVED BY DATE PERMIT NO. INFO ..EH 1324(11W.r,xS) EH 1418