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i S APPLICATION FOR PERMIT V SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. �Lll /d City Lot Size Job Address PM — LOwner's Name Address Phone Contractor . 'Address_ J—U _ -�� License NoY_ Phone_ TYPE OF WELL/PUMP: ' NEW WELL ❑ NLL REPLACEMENT 0 DESTRUCTION 0 , PUMP INSTALLATION ❑ SYS�RE ❑ OTHER ❑DISTANCE TO NEAREST: SEPTIC TANK SEWER LINEDISPOSAL FLD. PROP. LINEFOUNDATION AGRICULTU E OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA NSTRUCTION SPECIFICATIONS ❑ Industrial ❑-Open Bottom ❑ Manteca' / ia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy s' pe of Casing Specifications I`1 Public n Other - ❑ Delta D pth of Grout Seal Type of Grout 1 I I Irrigation Approx. Depth.Y I l Eas n S rfaee_Seal Installed by Repair Work Done [ I ' Type of Pump H,P. _` State Work Done Well Destructiom., i_I Well Diameter Sealing Material )top 50'1 "`Depth Filler Material ( w 501 -- TYPE.OF'SEPTiC.WORK: ' NEW.INSTALLATION I'I REPAIRIADDITION I DESTRUCTION i I (No septic system permitted if public sewer is -}-, available within 200 feet.) installation will serve: Residence Cummer L Other Number of living units: Number of bed Dams 1 Character of soil to a depth of 3 feet: _ Water table depth f SEPTIC TANK '❑ Type/Mfg Capacity I No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Oistanpe to nearest: well Fou ation Property line LEACHING LINE' Gl No. & Length of lines To L11 lengthert/size L FILTER BED Distance to nearest: Well Foundation Pro p Y Line SEEPAGE PITS I 1 Depth Size _ _ Nt ber _ _ l _ SUMPS {:1 Distance to n crest: WeII �_ 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, anc k. rules and regulations of the San Joaquin Local Health Di`s-trict. Home owner or licensed agent's signature certifies the following: "l 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." Contractors 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 componsa- tion laws of California.'; The applicant t call for? equired In pections. Complete drawing on reverse side. Signed X A' Title: f Date: �6 w � FOFQEPARTMENT USE ONLY -0 Application Accepted by Date Area i ir-rlror Grout In by atl/�/�flFinal Inspection by Date v l Additional Comments: ❑ Stk 466-6781 ❑ di 369-3621 ❑ Manteca a23-7104 © Tracy 835-6385 Applicant.- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave.; P.O. Box 2009, Stk., CA 95201 F tFEE AMQUNT PVE APA9VNT REMITTED CK RECEIVED BY DATE RERMIT'NO. 4 CAGki } EH 13$4Ilifv.I/@41 nD.. - . EH 11.29 .. .. . .- e u!