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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Y Z r Telephone (209) 466-6781 2s- PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 7 2 (Complete in Triplicate) ( d 7 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. f Job Address • v" '' T City Lot SizeA \ M Owner's Name u"t/(.ri"� Address - r k Phone L Contractor Address ff License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES (DISPOSAL FLD. PROP. LINE 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 Specifications144 ❑ Public K „ El Other ❑ Delta Depth of Grout Seal Type of Grout LJIrrigation 'N- _Approx. Depth F-1EasternSurface'Seal Installed by Repair Work Done ❑ Type of Pump H,P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') 'l1 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION iNo septic system permitted if public sewer is available within 200 feet.) vvv Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms jn� Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg CapacityNo. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal 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 r SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to 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 laws, 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, 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 applican us all for al re uiredins actions. Complete drawing on reverse side. Signed Title: Date: �~Z� FOR DEPARTMENT USE ONLY G Application Accepted by Date '�� `� Area7:6 Q� Pit or Grout Inspection by Date Final Inspe tion by Date --~ ut �lditional Comments: �i 2 Ci o CU t4,f 12P C9 EAStk 466-6781 TAodi -3621 ❑ Manteca 04 Tracy 835-6385 ' p licant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT'NO. + EH13-24(A EV.fl EH 14-28