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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL`TON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 4. Application is he 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 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District., h y Job Address ` �O " 2f - City Lot Size –PM Owner's NameJ� ^ Address si fin Phoney= q Contractors ddress .r Licegse No, Ph, TYPE OF WELL/PUMP: NEW W L ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ _7\, DISTANCE TO NEAREST'-SEP-TIC-TANK SEWER LINES DISPOSAL FLD. PROP. LINE l FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDS USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i El Industrial L1 Open,Bottom '\❑ Manteca Dia. of Well Excavation Dia. of Well,CBsing i ❑ Domestic/Private ❑ Gravel Pack E7 Tracy Type of Casing Specificationst ❑'Public } ❑ Other ^0 Delta Depth of Grout Seal Type of Grout ❑ Irrigation _�Approx. Depth ; Eastern Surface Seal Installed by pair Work Done Type of Pump ReEl �+ He P. State Work Done " { Well Destruction—D—,Well,—Diameter—. -----------Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial x Other } Number of livih g units: Number of bedrooms I Charac[er af_snil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg o Capacity.?2 J No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal { Distance to nearest: Well N—A^44oundation *;Property Line LEACHING LINE ❑ No. & Length of lines b 0 A_ _ Tot I length/size` t f FILTER BED ❑" 'Distance to nearest: Well jjFoundation Property Line f SEEPAGE PITS ❑ Depth 2 5- ~Size '�,,, Number SUMPS ❑' Distance to nearest: Well k`�Foundation Property Line DISPOSAL PONDS ❑. I 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—JoaquineLogkl Health District. Home owner or licensed agent's signature certifies thb-f61lowing: "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 taws 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- i tion laws of California." }} The applicant ust all forsquired i pections. Complete drawing on reverse side. �y l Title: Date: Signed *01 � ✓ —� FOR DEPARTMENT USE ONLY Application Accepted by _ !Rl 1.Date. 1o � Area Pito Grout Inspection b Date Final Inspection by��'��'� � — Date 3 '-1 [ additional Cor�iments: � �'�' � Y ❑ Stk 466-6781 ❑ L 1 369-36'11 ❑ Manteca 623-7104 ❑ Tracy 835-6385 ,' i P� 1 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O:B{ax 2009, Stk �CA_95201-� � FEE AMOUNT DUE AMOUNT REMITTED' CASH RECEIVEDd3Y DATE:_ PERMIT N0. �{2 IN I i + EH 13-241REV.1/1351 EH 14-29 ------