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APPLICATION FOR PERMIT ! SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA 1� Telephone (209) 466-6781 i3 f- 1 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. + I XX Job Address �� City aCC OW 'Lot Size ~ �2 3 7 PM f` ' r r `/' Owner's Name d Address �"�`� �� Phone �✓� Contractor ,r1 Address License No. Phone 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 t El Industrial ❑-Open Bottom ❑ Manteca Dia. of Well Excavation " Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ['l Public F Other = Ci Delta Depth of Grout Seal l Type of Grout : 1 . I I Irrigation --Approx.'Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction Y ❑ Weil Diameter Sealing Mat4 ial (top ') E Depth Filler Material (Below 501 f TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITIO 4 I 1 DESTRUCTION l 1 (No septic system permitted i public sewer is i t available within 200 feet.) Installation will serve: Residence! Commercial_ Other \ !. EC Number of living units: Number of bedrooms (��, jjj Character of soil to a depth of 3 feet: "`W _r�table depth SEPTIC TANK 171Type/Mfg Capacity No. lmpartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well oundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearel f. vVell Pouriclation Property me S SEEPAGE PITS l 1 Depth l Size Num r SUMPS " Ll Distance to.nears t: ��/Vell Foundation op`Ai ine DISPOSAL PONDS ❑ i hereby certify that I have prepared this applica 'on and tha-- work will be done in accordance with San Joa c ty rdinances, state laws, and rules and regulations of the San Joaquin Local ealth District. Home owner or licensed agent's signature certifi s the followin "I certify that in the performance of the work for wh this permit is issued, I shall not employ any person in such manner as to becom man's compensation laws of California."'Contractors hi g or sub-contracting signature' \ certifies the following: "I certify that in the perfor once of the w rk for which this permit is issued,t shall employ persons su 'act to workman's compensa- Jl tion laws of California." The applicant must call for all required inspectid & plQrawing on reverse side. Signed X Title: W e i Dat � +� ' l aFO RTNIENT USE ONLY ti ! Application Accepted by AA Date Area Pit or Grout Inspection by Date Final Inspection by E Date Additional Comments: ❑ Stk 466-6781 ❑ Lod/369-3621 ❑ Manteca f 823-7104 ❑ Tracy 836-&385 is 1 y R Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, t1C01 FEE MOUNT DUE T AMOUNT REMITTED CK RECEIVED BY DATE PERMIT INFO /� ([ CASH +.EHEH 14-28 13-24iREV.r/Nsl � D� 3ssVb t V i