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1" APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT v 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone 12091 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San laquin Local Health District for a permit to construct and/or install the work herein described. This application i Apo e No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin made in compliance with San Joaquin County Ordinanc Local Health District, if ou r B City Lot Size PM Job Address j L�-= Address _ m Phone � Owner's Name _ Contractor �� Addres License No. Phone 8 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 r FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF-WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t El Industrial El Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Type of Casing Specifications [I Domestic/Private ❑ Gravel Pack ❑ Tracy g I'1 Public Cl Other f-1 Delta Depth of Grout Seal Type of Grout I 1 Irrigation _ --Approx. Depth I I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State Work Dane _ It Sealing Material (top 501 Well Destruction ❑ Well Diameter 9 Depth Filler Material.(Below 50'l TYPE OF SEPTIC WORK: NEW INSTALLATION-1.1 REPAIR/ADDITION LI DESTRUCTIO available ADDITION systithinem emitted if public sewer is Installation will serve: Residence'—�Cornmercial Other , Number of living units: _1L__ Number of bedrooms Character of soil to a depth of 3 feet : Water table depth SEPTIC TANK ❑ Type/Mfg fes_- ',— Capacity'^T'"�_"'"""_� NB—Compartments PKG. TREATMENT PLT. ❑ 4 Method of Disposal Distance to nearest: Well t Foundation Property Line I LEACHING LINE ❑ No. & Length of lines V-A Total length/size I t Property Line FILTER BED ❑ Distance to nearest: Well Foundation p Y SEEPAGE PITS I 1 Depths Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line` ' DISPOSAL PONDS ❑ 0 j 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 i 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_workJor which this permit is issued, I shall not i employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature I 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 r sofCdliforni �iic� Ya applica st II f all quit insatedrawing o reverse de. � �� {?Jro� I Sig L/ ,Title: Date: d k f F USE ONLY S VO� Application Accepted by -._ f t _Date Area -� Date Final Inspection by Date Pit or Grout Inspection by Additional Comments: dlFitCGo € 7104 ❑ Tracy 835-6385 ❑ Stk 466-6781 ❑ Lodi 369 3621 ❑ Manteca 823 - Applicant Return all.copies to:.Environmental Health Permit/Services 1601.E..Hazelton Ave.,-P.O.Bax 2009,-Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. t + FH 13-24 IREV.1/n s) INFO EH 14-26