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i i I ? APPLICATION FOR PERMIT 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 Ruled 2�qd Reg�tion�s of the San Joaquin Local Health District. VU�� o ,/ ot Size 3 Job Address City r L Owner's Name f Address �__-?� �M Phone t � Contractor ' Address License No. Q " r-� Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTA'LL-ATION ❑ " -------'--SYSTEM REPAIR-0--" - `^'„°`=-OTHER•❑- DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. POOP. LINE FOUNDATION AGRICULTURE`WELL __- OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA-,_CONSTRUCTION SPECIFICATIONS 0^Industrial w ❑ Open Bottom 0 Manteca Dia:of Well Excavation Dia. of Well Casing LJ Domestic/Private D Gravel Pack El Tracy Type of Casing a^ Specifications 1 1-1 Public n Other x Cl Delta Depth of Grout Seal Type of Grout c -. Approx. Depth l I Eastern Surface Seal Installed by I I Irrigation i Repair Work Done ❑ Type of Pump _ H.P. r State Work Done Well Destruction C1 Well Diameter Sealing,Material {top 501 Depth 1l Filler Material (Below 501 - (`l I TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION,[.] DESTRUCTION I I !No septic system permitted if public sewer is d _ available within 200 feet.) . Installation will serve: Residence Commercial Other ' Number of-living units: -3- Number of bed ms *•+ N �� I _ Character of soil to a depth of 3 feet:r Water table depth " \� F \ SEPTIC TANK ❑ Type/Mfg Capacity d No. Compartments PKG."TREATMENT PLT. ❑ 4•. ` Method of Disposal c. Distance to nearest: WellFoundation.S _ Property.Line.�. { 1 LEACHING LINE ❑ No. & Length of lines �� y Total length/size FILTER BED ❑ Distance to nearest: Well ' Foundation Property Line r <'': 1 } Y .� Numor a SEEPAGE PITS l 1 Depth Size Nu/ SUMPS L1 Distance do nearest: Well Foundation Property Line t 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.' Home owner or licensed agent's signature certifies the following: "I certify-ihhthat-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 perfbrmance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of Calif rnia." The applica must c II to II required i ctio Complete drawing on reverse side. r Signed Title: Date: + FO EPARTMENT USE-ONLY Accepted by Date � �� U v Area ApplicationR Pit or Grout Inspection by -QiDae r 2 1 Final Inspection by Additional Comments: ' ❑ Stk 466.6781- --O-L•adiy 369=3621•-_ -0 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 1 FEE AMOUNT DUE AMOUNT REMITTED CASH INFO RECEIVED BY DATE PERMITN0. EH 13-24+" IREV.1i85i EH 14-28 rs