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APPLICATION FOR PERMIT �j SAN JOAQUIN LOCAL HEALTH DISTRICT a / 1601 E. HAZELTON AVE., STOCKTON, CA l� Telephone (209) 466-6781 1` PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) fid- /s 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 Ssn Joaquin CounSy rdinan a o,;49 f sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. J' � j r City ' of SizeGb PM Job Address i f * t Address + +✓�Y �� k �i Phone '? Owner's Name - Contractor's Name License No. � f Phone /- ? '� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT El Cl PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ' t I ED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 7 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation_ ia. of Well Casing ❑ Domestic/Private k ❑ Tracy Type of C Specifications ❑ Public ❑ Other epth of Grout Seal Type of Grout ❑ Irrigation _J4pprox. Depth rn ce Seal Installed by Repair Work Done ❑ Type of Pu H.P. State Work Dane Well Destruction f7 iameter Sealing Material (top 50'1 Depth Filler Material IBelow 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ available lwiti ine200 feet.) permitted if public sewer is Installation will serve: Residence— Commercial^ Other_ Number of living units: Number of b room,, Wafer table depth Character of soil to a depth of 3 feet: w _ SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments Method of Disposal PKG. TREATMENT PLT. ❑ Distance to nearest: Well — Foundation — Property Line LEACHING LINE ❑ No. & Length of lines F — Total lenTh/size FILTER BED ❑ Distance to nearest: W Property Line SEEPAGE PITS Depth Size timber SUMPS ❑ Distance to nearest: Well ndation Property Line DISPOSAL PONDS ❑ I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and I rules and regulations of the San Joaquin Local-Ffealth District fies the following: "I certify that in the performance of the work for which this permit is issued, I shall not Home owner or licensed agent's signature cefti 1 employ any person in such manner as t m becoe subject to workman's compensation laws of California."Contractor's hiring ct to workman's compense subcontracting signature certifies the following:"I certrfy that In the performance of the work for which this permit is issued,I shall employ persons subject tion laws of California." The applicant must call for all re ired in ap coons. Complete drawing on reverse side. �� 1 4i r Title: ctf i1t�Z�--' Date: Signed ' f FOR DEPARTMENT USE ONLY r Date Area Z Application Accepted by } �3 Data !Z J 1 Final Inspection b Date Pit or Grout Inspection by Additional Comments: �/ 4 • - 4� ❑ Stk 466-6781 ElLodi 369-3621 El Manteca 823-7104 7D',,Tracy 835 63&ri t ; 1 j ? i Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 96201 fr FEEREMRTED CK# RECEIVED BY DATE PERMIT NO. AMOUNT DUE AMOUNT ?� INFO CASH ` �] p.o0 ND !z-3 n ilia n ♦ EH 13-24(REV.10/831 EH 14-28 - _ - -- -