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{ 1 K APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE_ STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED f (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 I 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. f/Vf40, 0 t'1 V City *C Lot Size PM Job Address iAddress q.5 I/ �f2o 1, r it Owner's Name �1 tL' .- p Contractor Address 0 S SI MK 1`JZ0�Icense No.SSI Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION L—' PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing D Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'1 Public f_1 Other ri Delta Depth of Grout Seal Type of Grout ' I { I Irrigation —..Approx. Depth l I Eastern Surface Seal Installed by - v Repair Work Dane ❑ Type of Pump H.P. State Work Don 1 _ Well Destruction lld Well Diameter 1r Sealing Material [top 50') t w .- Depth .2,0t7 _' Filler Material (Below 50'I - — �, TYPE OF SEPTIC WORK: NEW INSTALLATION f a REPAIR/ADDITION [I DESTRUCTION I I (Nos ptic syshintem retitled if public sewer is availaInstallation will serve: Residence— Commercial Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: i Water table depth.- No.-Compartments SEPTIC TANK ❑ Type/Mfg Capacity � No.-Com p r PKG. TREATMENT-PLT: ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Ci No. & Length of lines Total length/size FILTER BED _0 Distance_to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size — Number \ , SUMPS L1 Distance to nearest: Well Foundation Property Line ']�\ � DISPOSAL PONDS El 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 Mmict. 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 i 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 applicant st call for all re red in pections. Complete drawing on reverse side. Signed X Title: Data: FOR DEPARTMENT USE ONLY Application Accepted by / L Date + L Area Pit or Grout Inspection by / D N I Inspection by Lr Additional Comment f �f e G �J ❑ Stk 466-6781 ❑ Manteca 623-7104 Trac 5.6385 -2- (S Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 96201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMiT'NO. INFO fpr 2C CASH �j� /` [/� 9 / +.EH 13-24(REV.1/Hs) -1� '` c.J � ° / ` r EH 14-28