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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 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. �.-_ 7 � PM 'l / City Lot Size Job Address Owner's Name Address Q'-n 11 Phone 012 Contractor ss_ License No` Phone TYPE OF WELL/PU P: NEIN WEL ❑ 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— INTENDED INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation I Type of CasingSpecifications ❑ Domestic/Private. ❑ Gravel Peck ❑ Tracy ❑ Other [7 Delta Depth of Grout Seal Type of Grout_ • " 11 Public _ f I I Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by `\ Repair Work Done (3Type of Pump t N.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 - �'1r Depth Filler Material(Belo 1 TYPE OF SEPTIC WORK: NEW INSTALLATION I1, REPAIR/ADDITION DESTRUCTION I I availabetic system ithin m (emitted if public sewer is Installation will serve: Residence— Commercial._ Other Number of living units: __ Number of bedrooms _— Water table depth Character of soil to a depth of 3 feet: SEPTIC TANK O 'Type/Mfg , Capacity No. Compartments w y F+ ( 1 Method of Disposal PKG. TREATMENT PLT. ❑ _ .. Pro art Line f Distance to nearest:Well t� foundation party LEACHING LINE f ❑ No. 8 Length of lines ' Total length/size 'TER BED '� ❑ Distance to nearest: WellFoundation k ( Property Line SEEPAGE PITS 4 t I Depth Size' Numher SUMPS 0 Distance to nearest: Well r- — Foundation Property Line DISPOSAL PONDS ❑ 1 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 DBtrict. r Home owner or licensed agent's signature certifies the following:"1 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-toworkman's compensation laws of California." Contractors hiring or sub-contracting signature i certifies the following: "I certify that in the performance of rhe work for which this permit is issued,I shall employ persons subject to workman's compensa- tion-laws/of 1 'California." Ir j The aapplicant nS t- r squire msuons,,Com�plalo. wing on re arse side. itle: Date: - a I rim FOR EPARTMENT USE ONLY Area_-.�. --- pp(icationAccBpted-pV __ Date 3aa Qd # Date Final Inspection by Date O Pit or trout In tion by _ -�--- ��y��O D rAdditioneF Comments: rf❑.Stk '46&6781 , ❑ odi '3693621 ❑ Manteca 823-7164 ❑Tracy 835-6385 Applicant. R urn all copies to: Environmental Health Par it/S ervices 1601 E. Hazelto Ave., P.O. Box 2009, Stk., CA 95201 .. D FEECK RECEIVED 8Y DATE PERMIT NO. INFO AMOUNT DUE AMOUNT REMITTED CASH 3.24 IREV.I r x sr �� -��`•CJ EH IC2