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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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 ! City Lot Size PM f t Owner's Name 2Address Phone &A Contractor j rid-ess Incense No. Phone TYPE OF WELL/PUMP:. NM WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER LJ 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Fl Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I i Irrigation _____Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done T Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 i TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION 1 1 DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_Y____ 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 i Total length/size, i FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 1 1 Depth Size _ Number SUMPS ❑ 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 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 Cal- tlnia." ,i The applic muss cal for al - ti . Complete drawing on reverse side. ` % Signed { '�\ 4 Title: T/>/�f�vJYZ � Date:IL ✓ — / �!� FOR DEPARTMENT USE ONLY 01 1000-1 Application Accepted by # Date S-f3�� Area Pit or Grout Inspection y bate Final Inspection by t-1"r Date * C�-e[/FC �iVic C Additions! Comments _ ❑ Stk 466-6781 EAodi k9F 3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED ASH RECEIVED 9Y DATE PERMIT NO. + EH 1324 1REV.I/H 51 EH 114-IM v