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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON ON AVE., STOCKTON, CA J 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. TMs application is made in compliance with San Joaquin County Ordinanco No.649 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address / iJl' �!l r'S City _ Size PM Owner's Name -_ �t._ - G �"Address _._ Phone -- J 19,-L (:f-zw Contractor�`' l l•��G Address _ License No._;i2-7114L Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION i 1 PUMP INSTALLATION : I SYSTEM REPAIR .0 OTHER F. DISTANCE TO NEAREST SEPTIC TANK SEWER I INES DISPOSAL Ft D.__ PROP LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS;SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS U Industrial ❑Open Bottom ❑ Manteca Dia. of Well Excavation _ Dia. of Well Casing (' Domestic/Private C Gravel Pack n Tracy Type of Casing Specifications r" Public F. Other (1 Delta Depth of Grout Seal Type of Grout Irrigation _- Approx. Depth I Eastmn Surface Seal Installed by Repan Work Done (l Type of Pump _ H.P. _. — _ State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') 1YPF OF SEPTIC WORK: NEW INSTAL IATION I RLPAIR!AODITION I I DEST82SI!2N ftp septic system permitted it public sewer is a�tz7ilable within 200 feet.l 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 F: Type/Mfg capacity" _ __— No. Compartments PKG. TREATMENT PLT. C Method of Disposal _ Distance to nearest: Well Foundation Property Line LEACHING LINE C No. & Length of lines Total length/size FILTER BED L) Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth _ ._ Size Number SUMPS it Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Ll 1 hereby certify that I have prepared this application and that the work will be(tone in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San,Joaquin local Health Diktrict. Home owner or liconsod 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 person to such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature cartifies the following: "I certify that in the performance of the work for which this permit is issued, I shall omploy persons subject to workman's compensa- tion laws of California." The applicant lmust call for all requireinspection Complete drawing on re�verrso side Signed X IJ. :i r? _ `� Z 1 i Title- f/F f�` ._.. _. Date: _ FODEPARTMENT USE ONLY Application Accepted by Date Arita Pit or Grout Inspection by oat Final Inspection by __ _ ______.___ Dat�� / Additional Comments: �f /.�/I /YI�rPS�� — __-- - - L) Stk 466-6781 entuldi 369-3621 ❑ Manteca 823-7104 EJ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave.. P.O. Box 2009, S1k., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PEHMIT NO. INFO + EH 1341(REV.r,NSr E p'a 7 _-- EH 1449