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APPLICATION FOR PERMIT SAN JOAQUINLOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 1209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED.' w-rte f . A�,,, (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.OrflinanGe No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. /V *, `O/� /)---o/ ) Job Address CityLai Size PM Owner's Name _ �` Address / f� " " `_ Phone �' 9 0 `Contractor Address License No. Phone j TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ F PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS' �J ❑ Industrial ❑ Open Bottom ❑ Manteca I Dia. of Well Excavation Dia. of Well Casing r q 1 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications V t ❑ Public ❑ Other l]Delta Depth of Grout Seal - Type of Grout r ❑ Irrigation —.Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. _ State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth - Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑i REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.)) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil-to a-depth of 3 feet: -- Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal .+ Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED © Distance to'nearest: Well Foundation Property Line SEEPAGE PITS . . Q'-.Depth.. Size Number SUMPS `�� l7l' "Distance to neo est:*_.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 V rule's.and regulations of.the San Joaquin Local Health District. Home owner or licensed he 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."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, Ishall employ persons subject to workman's compensa- tion laws of California." I The applicant must call for all required inspections. Complete drawing on reverse side. - r Signed x Title: t s Date: .S- FOR DEPARTMENT USE NLY R Application Accepted tryto Area • I L� Pit or Grout Inspection by �D,te �.., Final Inspection by Date s dditional Comme ts: I tk 466-6781 ❑ odi i. 369 3621 ❑ Monte 823-7104' LI Tracy 835-63B5. App icant- Return all copies to Environmental Health Permit/Services-1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 �� _ a i (WXI" FEE- _AMOUNT'pUE .-AMOUNT REMITTED=o- -RECEIVED BY � �?� ' DATE' PERMIT''NO. INFO~ i + EH 14-24IfiEY.t e51 .:...r S;�ti -EH 14-29 � �� - ��.a,-f 1..� _� � �