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µ APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON ON AVE., STOCKTON, CA Telephone (209) 466-6781 ��L (�d_� Y PERMIT EXPIRES 1 YEAR FROM DATE ISSUED aW , (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work here n described. This application is made in compliance with Sarr Joaquin County Ordinance No. 549 for sewage or No. 1862 for welUpump and the Rules and Regulations of the San Joaquin Local Health District. t Job Address J V �" ! � `-" City(5/0&%A�ot Size PM Owner's Name [ 1 t -L Address r ` Phone l I Contract_ Address J 4, �t � icense No. Phone_ j TYPE OF WELL/PUMP: /III NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ _ DISTANCE TO NEAREST: �w EPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE 11'TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 1 ❑ Domestic/Private ❑i Gravel Pack ❑ Tracy Type of Casing Specifications l� Public ❑ Other 171 Delta Depth of Grout Seal Type of Grout _ I I Irrigation h --Approx. Depth l I Eastern Surface Seal Installed by _ y Repair Work Done ❑ Type of Pump H,P. State Work Done jWell Destruction ❑ Well Diameter Sealing Material (top 501 } ! 1 i pepth Filler Material {Below 50') t TYPE OF SEPTIC WORK: NEW INSTALLATION l l REPAIRIADDITION l I DESTRUCTION (No septic system permitted if public sewer is vailable within 200 feet.) t Installation will serve: R ldence_ Commercial_____ Other dI: 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 j PKG. TREATMENT PLT, ❑ Method of Disposal z Distance to nearest: Well +x Foundation Property Line '- LEACHING LINE ❑ i No. & Length of tines Total length/size w FILTER BED ❑ Distance to clearest: Well Foundation Property Line ' SEEPAGE PITS I It Depth Size E Number iSUMPS L7.1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑. r 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." �I The applic t ust tail for I'alIl11 re d inspe tions. Complete drawing on reverse side. Signed X Title: Date: - -..—w , FOR DEPARTMENT USE ONLY>_ Application Accepted by _!rl Date Area I I Pit or Grout Inspection by Date Final Inspection by Date ii Additional Comments/�'!��2 ❑ Stk 466-6781 ❑ nodi 369-3621 ❑ Manteca 823-7104 C1 Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. INFO �� (CASFr\ + EH13-24tREV.iiK5) � L' 3. �d �tC,f,�rl - y EH 14-2e