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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 (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. S49 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address -0� D 1 C City {�/`��;� Lot Size PM Owner's Name S'6 -14 G�4�-0 �je� Address S�a� STy'r'E'�l� �� 14111,41— Phone � Cf Contractor vA16- 14wS4"' Address 1,fS: W<< �'tr License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER �SCJI A3 SLC1211FLd DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LI E FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _r 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 r Public l=1 Other ❑ Delta Depth of Grout Seal Type of Grout— I I 1 Irrigation .-Approx. Depth I 1 Eastern Surface Seal Installed by f Repair Work Done ❑ Type of Pump H.P. Well Destruction ❑ Well Diame er Sealing Material (top 50') Depth FT Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other i Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity 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 SEEPAGE PITS I I Depth Size Number SUMPS Ll 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, 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." The applica m t call for all ire i pections. om ete drawing on reverse side. Signed X Title: S'', Date: FOR DEPARTMENT USE ONLY 1 � Application Accepted by Data Area _ Pit or Grout Inspection by Date_-__� Final lnspecti by Date Additional Comments: t1( I ❑ Stk 466-6781 C] odi 369-3&1 1 ❑ Manteca 823-7104 Tracy 835-6'384"-- Applicant - Return all capias to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 955201 FEEINFO AMOUNT DUE AMOUNT REMITTED C KSH RECEIVED BY DATE PERMIT NO. r.EH1324IftEV.riK57 (- � EH 14-A