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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL"HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA k Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED {Complete in Triplicate) ` f 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 Ryles and Regulations of the San Joaquin Local Health District. , Job Address 7 �/' ' Ci u Lot Size ^`�G 5 G PM Owner's Name � � �` r1 � 1-9- Address ��` �L lug ` Phone 77— ContractorAddress License Na. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIOUIr ; A 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 y ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ; ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ' ---Approx. Depth El Eastern Surface Seal Installed by Repair Work Done. ❑ Type of Pump H.P. State Work Done S Well Destruction F ❑ Well Diameter Sealing Material (top 501) Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRU i0N (N septic system permitted if public sewer is ailable 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 n ,I SEPTIC TANK # ❑ Type/Mfg Capacity No. Compartments y PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line If LEACHING LINEA ❑ No. & Length of lines Total length/size i' FILTER BED ' ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS- 4' '❑ 3 Depth Size Number SUMPS ❑ Distance to nearest: Well - Foundation Property Line DISPOSAL PONDS i ❑ 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:fl,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." 1 t The applicant must call for all required inspections. Complete drawing on reverse side. Signed X Title: Date: `�� - -FOR DE RTMENT US ONLY — J Application Accepted by Date Area Pit or Grout Inspection by T Date ""'' "Fina ltispection by Date _Additional Comments: Stk 466-6781 LILodi 369-3621 ElManteca 823-7104 71Tracy 835-6385 " Applicant- Return ll copies to: Erivironmental Health Permit/Services 1601 E. Hazelton Ave„ P.O. Box 2009, Stk., CA 95201 ✓e FEE AMOUNT DUE. _AMOUNT REMITTED GASH RECEIVED BY DATE PERMIY'NO. INFO + EH 13-24(REV.1/s 5) l.. +� "�'1 Q� - EH 1429 cs �S �--v