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I ." t :... APPLICATION FOR PERMIT SAIN.,JOAQUIN LOCAL HEALTH DISTRICT 1,6x1 E. HAZEL T ON AVE., STOCKTON, CA `' Telephone (209) 466-6781 PERS'MIT EXPIRES 1-YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin,hocal Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San J,aquin County Oidihance No. 549 for sewage or No. 1862 for well pump and the Rules and Regulations of the San Joaquin Local Health District. r Job Address s ' City Lot Size PM 1Cev Owner's Name Address �� /0 { q r Contractor__...��''T�` I.�I `-"� Address ry" 1 1r_ f License No. *�� Phone_ d� TYPE OF WELL/PUMP: ,I� NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR M OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE FgUNDATION AGRICULTURE WELL OT L PITS/SUMPS �F INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUC SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of . Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Ty f Casing Specifications n Public f! Other C] Delta epth of Grout Seal Type of Grout _ I I Irrigation �11 -App(ox. Depth lJ Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P-' — Y —State Work Done t Well Destruction ElWell Diameter Sealing Material Itop 501 k Depth '-,Filler Material IBelowf501� —_ TYPE OF SEPTIC WORK: NI=W INSTALLATION f 1 REPAIRJADOITION I I DESTRUCTION; (No septic system permitted if public sewer is available within 200 feet.) I Installation will serve: Residence_ Commercial— Other fF` ' Number of living-units:•---�P^ Number of bedrooms ' f Character of soil to a depth)of 3,yfeet: Water table depth N. SEPTIC TANK ❑ IType/Mfg Capacity No. Compartments PKG. TREATMENT PLT. L1 ?� f Method of Disposal I I Distance to nearest: Well Foundation Property Line I�� # V. r LEACHING LINE ❑ I No. & Length of lines: f Total length/size FILTER.BED ❑ 'Distance to nearest: Well Foundation Property Line SEEPAGE,PITS 11 Depth I Size Number SUMPS D Distance to nearest: Well` Foundation Property Line DISPOSAL PONDS D. h. 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, an 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 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 call for all;required i cti s. Complete drawing on r se std �} , Signed X Title: " Date: L II� FOR DEPARTMENT USE ONLY T ! Application Acceptedby '" Date 12 Area RL Pit or Grout Inspection by , "Date s Final Inspection by Datg��6 Additional Comments: _,rl)Ii bone oC � al-is asrte[_ /�10• �� ❑ Stk 466-6781 ❑ Lotli 369-3621 ❑ Manteca 823-7104 Tracy 835-6385 Applicant - Return all copies 1: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk_ CA 95201 FEE AMOUNT,DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO, INFO CASH dl +.EH 13-24 IREV.1 Y A 5f !'�� I EH 14-26 �} { ff �N