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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL I 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 fora permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinate Np for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. -- ✓�//� l Job-Address {' 1 City . .Lot Size PM 9"I Owner's Name Address ^ Contractor U AddressJ�J /LQ/ icense No. �tq� �Phone ti TYPE OF WELL/PUMP: V NEW WELL.�! __._ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC'TANK 16f SEWER LINES DISPOSAL FLD. 16D / PROP. LINE FOUNDATION AGRICULTURE WELL OTHER_WELL.. - -- PITS/SUMPS 1 - INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �y j ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing X Domestic/Private 19 Gravel Pack ISI Tracy Type of Casing OLP ell Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal f Type of rout ❑ Irrigation ---Approx. Depth ElEastern Surface Seal Installed by f Repair Work Done ❑ Type of Pumpi H.P. State Work Done Well Destruction ❑ Well Diameter. Sealing Material (top 501 Depth i Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ iNdseptic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_{ 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. ❑ 11 - Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Le4tti of lines Total aength/size FILTER BED ❑ Distance to nearest: Well Foundation. Property Line f SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance fo nearest: Well Foundation Property Line - DISPOSAL PONDS '= ❑ hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state l7shall and_ rules and regulations of the San Joaquin.Local Health District. � 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, Inot employ any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature m 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 njUst call for all req`uii d�insspections. Complete drawing on everse side. Signed X Title: f Date: �2/18/2?7 F DEPARTMENT USE ONLY Application Accepted b DateArea Pit or GroutInspectio Date Final Inspection by Date Additional Comments: 7 !� ❑ Stk 466-6781 ❑ Lo6i 369=3621 ❑ Manteca 823-7104 ❑ Tracy 835-8385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009; Stk., CA 95X01FEE INFO AMOUNT DUE I AMOUNT REMITTED C RECEIVED BY DATE PERMIT NO. + EM 13-24(REV.5185) , EH 14-26 F