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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 (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 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. Job Address b 1u Ci Lot Size PM Owner's Name �� A�dress Phone 77) 07 Contractor / � ^ Address / -� '. ` jl v_ License No Phone �� TYPE OF WELL/PUMP: 'NEW WELL"D WELL REPLACEMENT ❑ !` DESTRUCTION ❑ ti PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ i OTHER D F -r DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, t PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELLPITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION.SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca ';Dia. of Well ExcBvatI0-n Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing. Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by _ Repair Work Done El Type of Pump H.P, '°' "'°'"State Work bone_ + Well Destruction ❑ Well Diameter -u'Sealing Material (top 50') Depth Filler Material (Beldw 501 + TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ %DESTRUCTION (No septic system permitted if public sewer is available within 200 feat.) f,.y i] Installation will serve: Residence— Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: # Water table depth ` SEPTIC TANK ❑ Type/Mfg Capacity j+ No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line lkk LEACHING LINE ❑ 'No. & Length of lines Total length/size i FILTER BED ❑ Distance to nearest: WellFoundation 'k .:Property Line P SEEPAGE PITS ❑ Depth + p _ .. �.Size SUMPS ❑ Distance to nearest: Well j ' Foundation.,\ 1A N Property Line DISPOSAL PONDS ❑ 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 a 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." The applic nt must call for7allruira 'ns c i s. Complete d awing o verse side.Signed TitleDate: tJ e) • FOR DEPARTMENT USE ONLY Application Accepted by Date —, Area Pit or Grout Inspection by Date Final Inspection by Date�' A ditional Comments: (.0 &) l 1 ],� ►� Stk 466781 ❑ LA 363621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 plicant- Retum all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT +rD^�UE AMOUNT REMITTED CA RECEIVED BY DATE PERMIT"NO. I + EH 13-24 4REV.1/$5) / EH 14-26 Z�