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f f APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCIKTON, CA I Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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. :- vy ` �• -f I Job Address ! 1 1 City Lot Size PM_. I 1 2 L l X Owner's Name ) Address 6' Phone �– -� o.� Contra, -Address License N1.4a'-L`")" S Phone �d U° TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy a Type of Casing Specifications 1-1 Public ❑ Other Ll Delta Depth of Grout-Seal Type of Grout I i Irrigation —,Approx. Depth I I Eastern Surface Seal Installed by (� Repair Work Done ❑ Type of Pump H.P.° ' State Work Done_ Well Destruction ❑ Well Diameter —Sealing Material (top 50'1 Depth F Filler Material IBelow 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION i I DESTRUCTID (No septic system permitted if public sewer is t vailable within 200 feet.) Installation will sere: 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. ❑ I Method of Disposal Distance fo 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'l Depth Size Number SUMPS ❑ Distance to nearest: Well 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 Joaquin Local Health District. Home o ed agent's signatuie certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in su manner as to a subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifi the following: "I ce ify that i the peLance the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion la \s of California.The applicant must call for a requi d inspeplete drawing on reverse side. r -Signed X Q Title: CLuILY Date: A S FOR DEPARTMENT USE ONLY Application Accepted I>y �' Date �U gree 13 . Pit or Grout Inspection Date Final Inspection by ZA Date Additional Comment ❑ Stk 466-6781 ❑ L di 369-3621 ❑.Manteca 3-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE KsV INFO AMOUNT DUE I AMOUNT REMITTED C SH RECEIVED BY DATE PERMIT'NO. l � + EH 13.24(FIEV,1 5) / EH 14.28 ��