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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone {209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ll W c (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, ( .y�e,,-� Job Address _l Q it U t r CJC.�_ _ Cit r019 Lot Size PM Owner's Name T`►�r r ! 1 !Q�T _ __ Address I I 0 Phone Op 5 Contractor � 'h C. Address 9Q3_1 License 04JIk3k Phone/&1,5&&/ TYPE OF WELL/ MP: 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 I] Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing El Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications {'l Public n Other H Delta Depth of Grout Seal Type of Grout I I Irrigation ApproK. Depth I I Eastern Surface Seal Installed by _ \ Repair Work Done n Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION t l REPAIR/ADDITION I I DESTRUCTIONX (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial T Other , Number of living units: I Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Type/Mfg Capacityuplknowri No. 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 CC�� SEEPAGE PITS I ) Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 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, 1 shall no 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 applicantImustatl for ail required inspections. Complete drawing on reverse side. Signed X Title: _& Date: 0 /f7 FO DEPARTMENT USE ONLY I Q Application Accepted by CQs=.t.t/� ,� .y_,y,,,,rr Date '8—L 4" -7 Area 3 Pit or Grout Inspection by �,_.. "Date Final Inspection by Date!—; -f Additional Comments —512Z ❑ Stk 466-6781 ❑ 0 I 369 1 ❑ 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 95201 INFO AMOUNT DUE AMOUNT REMITTED SASH RECEIVED BY DATE PERMIT'NO. + EH 13-24 1 REV.i/K 51 ( �j �y gk�l CH 14-26 17 t