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i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT rr 1601 E. HAZELTON AVE., STOCKTON, CA A-"p ```�L Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is heteby 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. 1 (0c" ob Address . � 1�� City Lot Size wner's Name AddressPhonep�ontractor Address (cense No. �Q U /3 / Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLA ION EJ. SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES --DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WE OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PRO EM ARI=A N, (RUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Mantel 'Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ y Type of Casing g Specifications 1-1 Public Cl Other Delta Depth of Grout Seal I I Irrigation A Type of Grout _ --App x th i I Eastern Surface Seal Installed by Repair Work Done ❑ Type of P p H.P. State Work Dane_ Well Destruction ❑ Well Diameter Sealing Mata i21 flop 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I'1 REPAIR/ADDITION [ ] DESTRUCTION (No septic system permitted if public sewer is Installation will serve: Residence LXCommercial— Other ` available within 200 feet.) Number of living units: --I— Number of bedrooms__-,_- Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacit Y No. Compartments PKG. TREATMENT PLT. ❑ . Method of Dispose! Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Wel! Foundation . Property Line SEEPAGE PITS I 1 Depth Size Number SUMPS Ll Distance to nearest: Well 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, and rules and regulations of the San Joaquin Local Health District. r 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 mus tail for all required in�s!pec"or, C mplete drawing on reverse side. Signed X- �� - Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date� Area Pit or Grout Inspection by DateFinal Inspection by Date h Additional Comments: � , ❑ Stk 466-6781 ❑ L ( 369-3621 ❑ 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 FEE AMOUNT DUE AMOUNT REMITTED INFO RECEIVED BY DATE PERM'-" r EH 13-24(REV.tik5) pn�,—.`, �L7 !�j(�'JEH 14-28 5 _00 -�� 7 ~4 6U"