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APPLICATION FOR PERMIT �I { *.. '-,�, SAN JO AQUIN LOCAL HEALTH DISTRICT � 1601 E. HAZE:TON 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 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 4 City OGS Lot Size PM Job Address Owner's Name L E,QT . /I�/' E &�c]dress d L7kJ� �3�3 Phone - p/ Contractor Address License No. Phone ' TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIO i 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 El Industrial ❑ Open Bottom El Manteca Dia_ of Well Excavation l Dia. of Well Casing medic/Private 11 Gravel Pack ❑ Tracy Type of Casing Specifications r Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout-- P rout - I Irrigation �..Approx Depth t I Eastern. Surface Seal Installed by HState Work Done — Repair Work Done ❑ Type of Pump , H.P. Well Destruction ❑ Well Diameter Sealing Material (top 50'1 pth I Filler Material (Below 501 — TYP F SEP C WORK: NEW INSTALLATION 1.1 RFPAIR/ADDITION i I DESTRUCTIO (NailabPeic St sn 200 feetiem .) if public sewer is Installation will serve: Residence �!r Commercial Other f t " Number of living units: _/— Number of bedrooms— .1 " t Character of soil to a depth of 3 feet( Water table depth SEPTIC TANK LI Type/Mfg Capacity No. Compartments I PKG. TREATMENT PLT. CI ,i Method of Disposal Distance to nearest: Well Foundation Property Line i LEACHING LINE LlNo. & Length of lines Total length/size f FILTER SED ❑ Distance r to nearest: Well Foundation Property Line I I SEEPAGE PITS I I -Depth 7 t Size _. Number -- SUMPS LlDistanceto nearest: Well Foundation Property:Line DISPOSAL PONDS ❑ 1 I hereby certify that I have prepared this application and that the work will be done in accordance with San.lo0quinAcounty ordinances, state laws, and i rules and regulations of the San Joaquin Local Health Di§trict. 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, k sha11 not employ any person in such manner as to become subject to workman's compensation laws of California Contractors hiring or subcontracting 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.' :t The applicant must call for all required inspections. Complig drawing.on reverse,side! Signed X Title: Date: FOR DEPARTMENT USE ONLY, n i Application Accepted by Date Area - I Pit or Grout Inspection by =:J[- Date Final Inspection by Dat Additional Comments: a : ❑ Stk 466-6781 ❑ Lod 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95291 FEE AMOUNT DUE AMOUNT REMITTED C K JP H RECEIVED BY DATE PERMIT NO. INFO (� C ) 5-10—P11-14R +.EH13-244REV.r/RS) OL ,�' J �D 1`47J� W-7 EH 14-26 I