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APPLICATION FOR PERMIT I SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 + PERMIT EXPIRES);NEAR FROM DATE ISSUED IComplete-in Triplicate) �. fx , - i 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 r 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.- - a.,_.. tin. �.wso Job Address noCi Lot Size PM_ Owner's Name Address �1 - Phone Contractor's Name __ ` _ _ Phone ' �` �` � License`No. '� � �` :� � � � K � Ty.PE-OF-WEL-L/-PUMP:'-,----"7- NEIN-WELLy0 WELL REPLACEMENT-0 DESTRUCTIO 1 PUMP INSTALLATION ❑ SYSTEM REPAIR+Cl OTHER ❑ ' r DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ DISPOSAL FLD. .PROP. LINE " FOUNDATION AGRICULTURE WELL OTHER WELL P'-PITS/SUMPS INTENDED USE TYPE.OF WELL' PROBLEMAREA CONSTRUCTION SPECIFICATIONS t ; ❑ Industrial © Open:Bottom ❑ Manteca Dia. of Well Excavation ;Dia:of Well Casing _ ❑ Domestic/Private + ❑ Gravel Pack ❑ Tracy Type of Cesind s-" Specifications ❑ Public Q Other ❑ Delta. -- Depth�of Grout Seal Type of Grout ❑ Irrigation _Approx. Depth ❑ Eastern Surface Seal Installed by ' Repair Work Done ❑ Type of"Pump H.P. State Work Done y �_ W Well Destruction Well Diameter - '� Sealing Material Itop 50') Depth - � Filler Material(Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑° REPAIR/ADDITION ❑ DESTRUCTION {No septic system permitted if public sewer is " - + s y?•,:{ _ ,Y available within 200 feet.) Installation will serve: Residence_` Commercial Other f Number of living units:'. '-Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK Water table depth L1Type/Mf9 �` Capacity No. Compartments ,PKG TREATMENT PLT.'❑ s Method of Disposal Distance to nearest:, Well 1 Foundation Property Line LEACHING LINE, ❑ No. & Length of lines .> Total length/size FILTER BED C7 Distance to nearest:- Well' 'Foundation Property Line SEEPAGE PITS El Depth Size Number SUMPS `' ❑ Distance to nearest: Wall'- " Foundation Property Line {� DISPOSAL PONDS CO ' # 1 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 0 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."Contractors 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." I n s � The - llicantAlast call for all quir ispeSpons. Complete drawing on reverse side. :Signed Title: Date: f i - - FOR DEPARTMENT USE ONLY Application Accepted by _ Data / // r� Area�s.r Pit or Grout Inspection by Date Final Inspection by _ Date Additional Comments: Stk 466.6781 ElLodi 389-3621 ❑ Manteca 823-7104 ❑ Tracy- 835-6355 Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 { i INFO AMOUNT DUE AMOUNT REMITTED-FEECK RECEIVED BY DATE` PERMIT"NO. +EH REY.10!$31 14-26 ` O � EH 1426 � V -.. w- - -