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�.. APPLICATION FOR PERMIT 1 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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. 1R62 for well/pump and the Rules and Regulations of the San Joaquin I Local Health District. Job Address City � Lot Size PM Owner's Name Address Phone r 1 I Contractor 5 Address 2!.w �[?l� /� License No.j!kS�� -Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION gr.0A0aM0fr.YSTEM REPAIR OTHER L1 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 Specifications, s t 1-1 Public n Other ❑ Delta Depth of Grout Seal 5� Type of Grout_-C5YF- 1r7—. I Irrigation �..Approx. Depth i I Eastern Surl�ce Seal Installed bygffn 1� Repair Work Done ❑ Type of Pump S H.P. 7`Z— State Work Done .fAJ3T�9l�/t 4 i2P L1AA6E Well Destruction ❑ Well Diameter Sealing Material-Etop�wl .!N �� 4IPde27 � � # � Depth Filler Material (Below 5U') TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION {:l DESTRUCTION 1 I (No septic system m rented if public sewer is availabInstallation will serve: Residence= Commercial— Other Number of living units: Number of bedrooms , _ --_ 1INt Character of soil to a depth of 3 feet: Water table depth: SEPTIC TANK ❑ Type/Mfg Capacity `. No. Compartments T� ,+ PKC. TREATMENT PLT. ElMethod of Disposal,. -. ' � Distance to nearest: Well Foundation Property Line / LEACHING LINE ❑ No. & Length of lines Total length/size) I ! FILTER BED ❑ Distance to nearest: Well Foundation Property Line # I � SEEPAGE PITS l 1 Depth Size Number SSUMPS Cl 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. r 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 far which t, his permit is issued I shall,employ_pers_ons subiect.,to,workman's compens� tion laws of California." " 4 The applicant r I re qu' ctions. Complete drawing on rev se side. / Q' Signed X Title: Date: FOR DEPARTMENT USE'ONLY Application Accepted by y� �7 " f]ate Area Pit or Grout Inspection by Date��" / Fnal Inspection b Date2 Additional Comments: t ❑ Stk 466-6781 ❑ Ladi 1 ❑ Manteca 823-7104 ❑ Tracy 835-6385 ��I 4nh114- 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. INFO �7 .. t o EH 13-24(REV.i r EH 14-2a