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f ' 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 Rules and Regulations of the San Joaquin Local Health District. Job Address gj City f Lot Size PM Owner's Name r T 1 �S t V'1 Address Phone 41 !t Contractor �4 Address '�^� # License No.014,0/4e Phone 37 74 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 1 , PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER �.ailt S 19A DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE r FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing a . Specifications FI Public Other ❑ Delta Depth of Grout Seal Type of Grout com I I Irrigation _.-Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') -o mt? _ W", Depth f Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION f I DESTRUCTION I I (No septic sy's'tem permitted.if pu6Gc sewer is I available within 200,feet') Installation will serve: Residence 1 Commercial— Other '` ` '_J Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal 0 4 Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line M 1 SEEPAGE PITS VI Depth Size Number - SUMPS ❑ Distancetonearest: Well Foundation Property Line DISPOSAL PONDS ❑ I I 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 Oii;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 or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." { The applicant st caH-tor all eq 'rad pe�Ct' Complete drawing on reverse side. Signed X 'r'r'f` f� Title: "_ � Date: I t F R DEPARTMENT USE ONLY Application fi> PP Accepted p b Y Date � Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 104 ❑ Tracy 635-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE '✓ r�.W1 t dam.✓ �8��a�d 4�.1�a�✓�� INFO AMOUNT DUE` AMOUNT REMITTED C SH RECEIVED BY DATE PERMIT'NO. -:5 3.5 OC� �3z +:EH 13-24 4REV.i 1H 5) EH 14-28 4