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APPLICATION FOR PERMIT ti SAN JOAQUIN LOCAL HEALTH DISTRICT r 1601 E. HAZEL i ON AVE., STOCKTON, CA Telephone (209) 466-6781 [PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i � (Complete in Triplicate) l 1 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 far weN/pump and the Rules and Regulations of the San Joaquin i Local Health District. Job Address City CO Lot Size PM A� �4lra�� Phone Z O ! Owner's Names ,. Address Contractor�� ■o r I Address LicenseNo. 3 `Thane_ g T OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ l PUMP INSTALLATION F1SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: NK SEWER LINES DISPOSAL FLD. PROP. LINE f FOUNDATION GRICULTURE WELL OTHER WELL PITS/SUMPS i.a INTENDED USE TYPE OF WELL PROBLEM AREA UCTION SPECIFICATIONS [IIndustrial. ❑ Open Bottom ❑ Manteca Dia. of Well Exc Dia. of Well Casing 1-1 Domestic/Private ElGravel Pack' LJ Tracy Type of Casing Specifications ; } e of Grout _. FI Public ❑ Other (-1 Delta Depth of Grout Seal , I I Irrigation• --..Approx.-Depth.ri[-I Eastern— -Surface Seal Installed by " S _ Repair Work Done ❑ Type of PumpState Work Dane', H. Well Destruction ❑ Well Diameter, Sealing Material (top 501 Depth Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRlADDITION l I DESTRUCTION l ))(No septic system permitted it public sewer is ailable within 200 feet.) Installaiion will serve: Residence_ Commercial_ Other �l Number of living units: Number of bedrooms Character of soil to a depth of 3 feet:f Water table depth SEPTIC TANK ❑ Type/Mfg I Capacity No. Compartments �li 3 El Method of Disposal PKG.TREATMENT PLT. I r Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation -Property Line a +I SEEPAGE PITS I I Depth 'I 'Size Number I I SUMPS Ll Distance to nearest: Well Foundation Property Line ? , f i DISPOSAL PONDS ❑ H I hereby certify that I have prepared this'applicationyand that the work will be done in accordance with San Joaquin county or state laws, and rl rules and regulations of the San Joaquin Local Health District. , kl 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 I 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- l tion laws I:of California." I The applic cal or all requ4 ad inspections. Complete drawing on reverse side. Si ne Title: ]tc� - �` i - Date; X gr~{ } � k FOR DEPARTMENT USE ONLY ; Application Accepted by date Area 1 41 Pit or Grout Inspecti by Date Final Inspection by + Date !1 a Additional Comments: ❑ Stk 466-6781 ❑ odi 369-3621 ❑ Manteca� M-7104-- ❑ Tracy 835-6385 Applicant - Return all copies to: Envirorimantal Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 F FEE AMOUNT DUE y AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. INFOI. r.EH 13-24(REV.+/n h) IV-161 t EH 14-25 1