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APPLICATION FOR PERMIT I SAN JOAQUIN LOCAL HEALTH DISTRICT ( 1601 E. HAZEL T ON AVE., STOCKTON, CA I 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin i Local Health District. i ' Job Address City Lot PM Owner's Name . Address ' yC�. Phone CY at2 Contractor SS L `" License No. , �d Phone 4 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ f PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ i DISTANCE TO-NEAREST:;SEPTIC TANK SEWER LINES _ _ DISPOSAL FLD. PROP. LINE FOUNDATION AGRIC LT f WELL OTHER WELL PITS/SUMPS _ -INTENDED USE a TYPE OF WELL PROBLEM AR CONSTRUCTION SPECIFICATIONS 4 CI Industrial f ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia..of Well Casing r ❑ Domestic/Private j ❑ Gravel Pack Q Tracy _ Type of Casing Specifications a til 1 Public ❑ Other n Delta " Depth of Grout Seal e "Type of Grout I.1 Ir6oation f e. ��Approx. Depth 1 1 Eastern Surface Seal Installed by �... Repair Work Done ❑o Type•of Pump H.P'. State Work Done_ x Well Destruction' ❑ -Well Diameter Sealing Material Stop 501 f -� 'Depth 3f iller Material.(Below 501 J y > TYPE OF SEPTIC WORK: NEW INSTALLATION IT REPAIRlADDITiON l 1 DESTRUCTION I 1 INo septic system permitted if public sewer is available within 200'feet.) Installation will serve: Residence _Commercial Other t Number of living-units: " —Number of bedrooms J 1. Character of soil to a depth of 3 feel:"" """ -- Watertable depth r" i SEPTIC TANK C] Capacity Capacity No. Compartments PKG. TREATMENT PLT.❑ A, , _ Method of Dispo A Distahce to nearest: We14100 A_ Foundation Property Line `N'. E .':' s LEACI�ING LINE ❑ No. & Length of lines To I I ngth/size ILTER BED ❑ Distance to nearest: Well Foundation a Property Ling r � SEEPAGE PITS I I Depth' Size Number SUMPS ❑ Distance to nearest: Well �. Foundation_IjciProperty Line,' 4 DISPOSAL PONDS ❑ t , fi 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 rules and regulations of the San Joaquin Local Health Di§trict. - 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 I 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 ust call for all re iced inspe ions. Complete drawing on reverse side. Signed F Title: / Date: FOR DEPARTMENT USE ONLY `. E ✓ G�.� Application Accepted by oat e" t s Pit or Grout Inspection cbbyy,/� G Date Final Inspection by 'Q Date Additional Comments: t ❑ Stk 466-6781 0 od369-1%21 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 1 FEE} INFO AMOUNT DUE AMOUNT REMITTED CK 0 CASH RECEIVED BY DATE PERMIYNO. ' +.EH 13.241REV.iiKsi 'd ...�-.�._ ..��L.►'�.. ". �/�� J U. _t�U..�J"- `