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r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 No Wim. PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (� Z (Complete in Triplicate) NX 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 3 4 LCitj Q „ '� of Size PM Address V Y Phone Owner's Name 1� ) (� 7 : �p �( Contractor�� K � LA�N AddressTO�� l� L�� e Licestse N6'� ne4 7�TYPE OFWELL/PUMP: NEWELL ❑ WELL REPLACE ENT ❑ DESTRUC ,� PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD- PROP- LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS [I Industrial F1 Open Bottom ❑ Manteca Dia. of Well Excavation Dia- of Well Casing E3 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f'l Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout 1 F. I I Irrigation _-.Appf0K. Depth l I Eastern Surface Seal Installed by - N :3 Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION 1WINo septic system permitted if public sewer is available within 200 feet.) 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 No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size _ Number _ SUMPS Ll Distance to nearest: Well Foundation 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 l 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 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, 1 shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. / k SignedX Title: a Date: " t? F. DEPARTMENT USE ONLY // Application Accepted by Date 6_(1 Area Pit or Grout Inspection by Date Final Inspection by/Pc Date Additional Comments: 2/ ` Z -�L ",/ ��'-Ss-t�r�" `u s` - ❑ Stk 466-6781 EILoji 36-3Ff ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1609 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO +. f�C-A$ EH 13,241REV.1/x51 H � �i EH 14-28 C r � v .