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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE i ON 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 3 Local Health District. , Q f o Job Address City' L" Lot Size L 1 PM t 4 /L�/1fA) Address Phone Owner's Name � ; Contractor Address_ � ��/ Z� License No.�—Phone t TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i PUMP INSTALLATION ❑ 'SYSTEM'REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE . FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS y— INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation S ecifrcations ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing p Depth of Grout Seal Type of Grout ❑ Other C7 Delta P M Public _ I I Irrigation Approx. Depth 1.1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 k Depth Filler Material (Below 501 { TYPE OF SEPTIC WORK: NEW INSTALLATIIIA ON I.1 REPAIR/A[RATION>< DESTRUCTION I I (Noavaseptic system m permit �ed if public sewer is Installation will serve:. Residence J J;Commercial : Other i Number of living units: Number of bedroomsr Charaeiier of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg � " �i Capacity No. Compartments Method of Disposal PKG. TREATMENT PLT. ❑ --, � j �/ - "Distance to nearest: Well /C�— Found`at'ion,,�� Property Line LEACHING LINE No. & Length of lines Totah,lengthl"srty I� FILTER BED ❑ Distance to nearest: Well Foundation .��Property-L'ine t SEEPAGE PITSI i Depth SUMPS �- Number �' oundao iin�2f_ Property Line FT I hereby certify that I have prepared this application #: Distance to nearest:``" Well� I DISPOSAL PONDS ❑ �' ; n and that the work will be done in accordanZe with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies[he following: "I certify tha'r•in-fhe i)ertormance'ofghe-work for which this parmit is issued, I shall not employ any,person in such manner as to become,stibiect_to-workman's compensation taws-Qf California." Contractor's hiring or sub-contracting signature certifies the"following: "I certify that in the-performance of the Nt rk,for whicli This permit is issued, I shall employ persons subject to workman's compensa- ,; tion laws of California." ( The applicant must call for 11 requir inspections. Complete drawing on,raverse side. j, M Titte._j _ Date: Signed X k F(�R D RTMENT USE ONLY ; �i/ Rata, 1 Area / Application Accepted by 1f r Date Final Inspection by, Date Pit or Grout Inspection by j Additional Comments: ❑ Stk 466-6781 ❑ Lodi 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., C 95201 l �a. 1REV.1/K51 I - - t RECEy T � FEE CK A 'PERMIT-NO „ AMOUNT - AM011NT-REMTTED - w-C7SFf� ' NFO EH13-24 ^� EH 14-26 -