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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 456-5781 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 compli na ce with San Joaquin County Ordinance No.549 for sewage or No. 18&2 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address City / Lot Size PM Owner's Name AddressPhone t / f Contractor's Name License No. — �"�3 7(l 3 Phone "6 6D!7 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. `~ PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL - PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom-z F ❑ Manteca Dia. of Well Excavation Dia. of Well Casing _ ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Cl Public 11 Other F) Delta Depth of Grout Seal Type of Grout LI Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by r �. Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction 11 Well Diameter Sealing Material (top 501 Depth ---Filler Material (Below 501 � TYPE OF SEPTIC WORK: NEW.INSTALLATION ❑ 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: O Number of bedrooms' 0 Character of soil to a depth of 3 feet: Water table depth +S a SEPTIC TANK ❑ Type/Mfg— Capacity s No. Compartments PKG. TREATMENT PLT. ❑ „+ '�' �+ t Method of Disposal 0i Distance to nearest Well Foundation Property Line LEACHING LINE No. & Length of lines _ To_tal n g Z leth/size rte!J- FILTER BED C7 Distance to nearest: Well /d/J r�” Foundation— Property Line+ SEEPAGE PITS Depths Size .33 Number I ' SUMPS ❑ Distance to nearest: Well ,'Foundation $f Property Line DISPOSAL PONDS ❑ v I hereby certify that./ 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 Loci? Health-DiWiicl. 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 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, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for II requ' d inspections. Complete drawing onreve side. Signed Title: ' 2ff-1h —_ Date: FOR DEPARTMENT USE ONLY Application Accepted by Date `+`S Area Pit or Grout Inspection by Date Final Inspection by P Additional Comments. L,�, SA ❑ Stk 466-6781 369-3821 ❑ Anteca 823-7104 ❑ Tracy Applicant- Return all c 'es to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO + EH14-24(RVI 101831 1 EH 1426 1S /1 �S i