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APPLICATION FOR PERMIT j SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CAS ii 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 rs made a 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 t Local Health District, CityLot Size PM 1 Job Address r Phone; ,ria ddress 4 , I— Owner's Name � _ Phone Address License-Nor� Contractor DESTRUCTION ❑ TYPE DF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 11 PUMP INSTALLATION El SEWER REPAIR 11 OTHER ❑ " SEWER LINES DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK AGRICULTURE WE OTHER WELL PITSISUMPS FOUNDATION �( INTENDED USE TYPE OF WELL PROB------ Al EA CDN5T TIDN SPECIFlCIQNS Dia. of Well Casing 14\ ' Dia. of ell Excavation �l El Industrial ❑ Open Bottom ❑ Manteca Type f acing Specifications I I-) Domestic I Private ❑ Gravel Pack ❑ Tracy r Type of Grout Ll Other F1 Delta D th Grout Seal, ❑ Public -Approx. Depth I I Eastern, urfac Seal Installed by I l IrrigationState Work Done �` H.P. Repair Work Done ❑ Type of Pump Well Destruction ❑1�,:Weld Diameter Sealing Material (top 501 Depth Filler Material iBelow 50') TYPE OF SEPTIC WORK: NEIW INSTALLATION {1 REPAIRlADDITIO l 1 STRUCTION I I (vailablelc thin 200 feetstem .) if public sewer is I Ir �' - I Installation will serve: Residence Commercial, Ot er Number of living units: Number of bedrooms � ater table depth Character of soil to a depth of 3 feet: h No. Compartments f Capacity. --- SEPTIC TANK ❑ Type/Mfg i Method of Disposal PKG. TREATMENT PLT.n— ; _P�operiy Distance to nearest: Well Foundation 1 Total lengt isize LEACHING LINE ❑ No. & Length of lines property Line FILTER BED ❑ Qistance to nearest: Well Foundation •-� ' SEEPAGE PITS f I Depth Size Number ' SUMPS ❑ ':Distance to nearest: Well Foundation Property Line DISPOSAL PONDS i ❑ �I 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 k rules and regulations of the San Joaquin Local Health District. ollowing: "I certify that in the performance of the work for which this permit is issued, I she not Home owner or licensed agent's signature certifies the f employ any person in such manner as to become subiect to workman's compensation laws of California." Contracednsrsub subject to wo�kman!scompensa- certifies the following: "I certify that in the perfofmance of the work for which this permit is issued,I shall employ p l tion laws of California." The applicant us-call foruired ins ctions. Complete drawing on reverse side. a - r i € Date: 'tie: . Signed X ! ;. !� FOR DEPARTMENT.USE ONLY *. , ' Area i k T Date Application Accepted by 0 i IiInspection,"� n�:� Date Date Final by"" `; Pit or Grout Inspection by3. Y. i Additional Comments: ❑ Stk 466-6781 ---'❑ Lo �di 369=3621 ❑ Manteca' 823-7104-. —0 Tracy 835-6385---^'.-'^"'— Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I CK RECEIVED B GATE PERMIT•NO- FEE AMOUNT DUE AMOUNT REMITTED CASH INFO _� ;v --773 r.EM 13-24 lr1EV., EH 14-25 ;i