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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 1209? 466-6781 PERMIT EXPIRES 1"YEAR FROM DATE ISSUED {Complete in Triplicate) Application is hereby made to the San'Jbaquin Local Health District for a permit to construct and/or install the work herein described. This application is p made in compliance with San Joaquin Cbunty Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin r Local Health district. I . Job Address City — Lot Size PM 17 Owner's Name '—t' Address / Phone Contractor �ic.z-nom I� Address rte' G License Nol.�lo 2.3 2 3 Phon TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION V SYSTEM REPAIR C OTHER ❑ DISTANCE TO NEAREST_ SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS y M Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑Domestic/Private 1-1 Gravel Pack ❑ Tracy Type of Casing Specifications I, FI-Public F) Other Cl Delta Depth of Grout Seal Type of Grout _, " I I Irrigation " x. Depth I I Eastern Su at Installed by Rep-it-Work Done 4 Type of Pump Ste.- H.P. � a � State Work Done - Well Destruction ❑ Well-Diameter Sealing Material Itop 50') Depth— --I '-'Fillee'Materiai-{Below-50') " TYPE,OF SFPTIC"WORK: "NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I l INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residences Commercial Other 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 Distance to nearest: Well Foundation !Property.Line LEACHING LINE ❑ No. &.Length of lines Total length/size FILTER SED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS i 1 Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line i DISPOSAL PONDS ❑ I hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, ander rules and regulations of the"San Joaquin Local Health Dilttict. 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 of 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." I The applicapMust,,call for all required inspections. Complete drawing on reverse side. I Signed X itle: . Date: 17 [1 1\�1 FOR DEPARTMENT USE ONLY Application Accepted by �%�.�C6,56, Date �1 ~� Area d �� i Pit or Grout Inspection by Date s Final Inspection by Date Additional Comments: CEIl� _..:_ t o od ' ❑ Stk 466-6791 ❑ L ddi 369-3621 ©Manlca -7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA 95201 I FEE AMOUNT DUE AMOUNT REMITTED C SH RECEIVED BY DATE PERMITNO. INFO r +.EH13-24IIREV.1/x51 r EH 14-26 e.