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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT r 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 rPERMIT 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. r a Job Address City Lot Size PM ' r6io Owner's Name Address Phone Contracto f D ^ddress �� License No. Phone `� _ _ t TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION l PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER'❑ u � DISTANCE TO NEAREST: SEPTIC TANK. SEWER LINES DISPOSAL FLD. PROP. LINE_ T° FOUNDATION "1- AGRICULTURE WELL 'N"OTHER WELL PITS/SUMPS INTENDED USE = TYPE OF WELL k. PROBLEM AREA,ti,CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ;Dia. of Well Casing•i ❑ +Domestic/Private ❑ Gravel Pack ❑ Tracy a Type of Casing Specifications, ( ! Public ❑ Other [7 Delta -.—tDepth of Grout Seal 1 Type of Grout 1 1 Irrigation _..Approx. Depth., I 1 Eastern Surface Seal lnstalled'by`• 4s ' t _ i Repair Work Done 'ED' Type of Pump _ H.P. - State Work Done�` ; Well Destruction _ ❑ Well Diameter"' 1 Sealing Material (top 50' �ry ti 4Depth Fill r Material (Belo ') TYPE OF SEPTIC WORK: 'i NEW VNSTA TION Cl REPAIRIADDITION Or DESTRUCTION l I.(No.septic system permitted if public tewer.is i r `w ► - �. available within 200 feet.i „ - t Installation will serve: Residence Commercial Oihe Number of living units � Number of bedrooms- +. ' ' h Character of soil to a depth of 3 feet: Water'fable depth` ` d SEPTIC TANK [-] Type/Mfg Capacity_ No. Compartments PKG. TREATMENT PLT. ❑ Method of Dis osal Distance to nearest: Well Foundation /0 Property Cine_ l a �^ --i - LEACHING LINE ❑ No. & Length of lines by Total length/size r FILTER BED ❑ Distance to;nearest: Well Foundation _.- Propertine - v SEEPAGE PITS I I Depth Size _ Number a SUMPS Ll :Distance to-nears Well�-- Foundation�-e3 Property Line r DISPOSAL PONDS ❑ 1 1 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 Di$trict. wT ' 3 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 must call f 11 require inspections. Complete drawing on reverse side. f 4r, Signed X ' ' Title: Qi _r Date: +�FOR DEPARTMENT U E ONLY T 8f Application Accepted by Date Areaa r Pit or Grout Inspection by Date Final inspection by Dat Additional Comments 11Stk 466-6781 i -3621 ante 823-7104 ❑ Tracy 835-6385%'j Applicant- Return all copies to: Environmental Health Pefmit/Services 1601 E. Hazelton Ave., P.O. Box 2009; Stk., CA 9520 r� , +0111C u4.0 IFEE NFO AMOUN DUE `t AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'NO. F "�.EH 13-24 IREV.1 i y si EH 14-26 V 4