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APPLICATION FOR PERMIT J SAN JOAQUIN LOCAL HEALTH DISTRICT [---- 1601 E. HAZELTON AVE., STOCKTON, CA Telephohe (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 welllpump and the Rules and Regulations of the San Joaquin Local Health District. Job Address City�/� Lot Size PM '�ci Phones Owner's Name _ �� i*W W Address - -- Contractor—-- -� Address �- License No. Phone E OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑-- -�^��^^ - DISTANCE TO NEAREST: TANK SEWER LINES �____� DISPOSAL FLD. PROP. LINE FOUNDATIO AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom D Manteca Dia. o Excavation Dia. of Well Casing `�(� LJ Domestic/Private 71 Gravel Pack LJ Tracy a Type of Casing Specifications t (+�J [I Public F1 Other j ❑ Delta Depth of Grout Seal Type of Grout 1 1 Irrigation _.-Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump W.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADOITION I I DESTRUCTIO i No septic system permitted if public sewer is ilable within 200 feet.) Installation will serve: Residence Commercial_+ Other + Number of living units: Number of bedrooms_15 Character of soil to a depth of 3 feet: - z%,.. Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ 5 Method of Disposal Distance to nearest: Well ;� Foundation Property Line L - /O cSomwv-0444 A" LEACHING LINE ❑ No. & Length of lines _ Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ r 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 employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring ciesub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, l shall employ persons subject to workman's compensa-' tion laws of California." The applican ust call If r all re fired inspections. Complete drawing on reverse side. Signed Title: _li,. A4*L , ;T�ZCrocrt.r� »t![_c i Date: FOR DEPARTMENT USE ONLY Application Accepted byDate_ Area f Pit or Grout Inspection y Date Final Inspection by Date Additional Comments: ' ❑ Stk 466-6781 ©hod 369-3621 0 Manteca 823-7104 ❑ Tracy 836-6385 ; Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 _ FEE INFO AMOUNT DUE AMOUNT REMITTED- CASH CK 0 RECEIVED BY DATE PERM(IIT''NO. +•EH14261REV.tirt5l �Y ver ` �I—� /7 ✓� 7 1 I