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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T 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 Local Health District. �Mat Job Address CitVC 'Ct Size PM Owner's Name V V ' Address Phone I 2,(5Contractorddress r cense No. �d Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRU ION f 'PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 4 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ 16dustrial ❑ Open Bottom 0 Manteca Dia. of Well Excavdtion Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing ; Specifications M Public FI Other F1 Delta Depth of Grout Seal 1 .,Type of Grout O I I Ireigation —.Approx. Depth 1 1 Eastern Surface Seal Installed,by } `� `1 Repair Work Done ❑ Type of Pump H,P. State'Work Done Wella Destruction ell Diameter Sealing Material It op 50') _ f f Depth Filler Material I$eIDW 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION i I DESTRUCTION l I INo septic system permidted if public sewer is available within 200 feet.) X a Installation will-serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: S Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments �PKG. TREATMENT PLT. ❑ Method of Disposal x i s Distance to nearest: Well Foundation Pr6pertyLine m -LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l 1 Depth Size Number t f -SUMPS ❑ Distance to nearest: Well Foundation Property Line V 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 reg ons of a San Joaquin Local Health District. ;t# Home owner r I ens a is "gnature ce " ' s the following: "I certify that in the performance of the work for whi.1h this permit is issued, I shall not 'employ any rs in ch m n as to ec a subject to workman's compensation laws.of..California.''Contractor's hiring.or sub-contracting signature certifies the f Ito ing: ' ertif at in the or ante the work for which this permit is issued, I shall employ persons subject to workman's compensa- r tion laws of mia." The lapplic t st 11 r i ad ns i C late drawing on re r e sid a Sigrid �" r Title: Date: TFOR DEPARTMENT USE ONLY Application Accepted by Date 7^ ZU l Area Pit �Grout inspection by Date 7�� Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ L di 369-3621 ❑ Manteca 823-7104 Q Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 �L P t INFO FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT N0. a , +.EEH 3-24 H 14-2e(REV. �? 117 J7 ^p f