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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT F 1601 E. HAZEL T ON AVE., STOCKTON, CA F6 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 Fit made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for wel;/pump and the Rules and Regulations of the San Joaquin Local Health District. �y c Job Address `-� / � 5.. 1 :� City - c/7 6IC Lot Size A/11 PM_ Qwner's Name �! Address _ / 1}i _ Phone ^� Contractor r � � t.&i Address � Q �t� License No. -Phone � C TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION F) SYSTE EPAIR Ll OTHER El (� DISTANCE TO NEAREST: SEPTIC TANK WER LINES DISPOSAL FLD, PROP. LINE { FOUNDATION AGR ULTUR ELL OTHER WELL PITS/SUMPS 11f INTENDED USE TYPE OF WELL PROBLEM AREA ONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca ia. of Well Excavation Dia. 'of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy T e of Casing Specifications n Public ❑ Other Ll Delta Dept of Grout Seal Type of Grout ! I Irrigation �Approx, Depth i l I Easte SurfaceSeal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth f Filter Material f Beiow 50') YPE OF SEPTIC WORK: NEW INSTALLATION r,. REPAIR/ADDITION I I DESTRUCTION I 1 1No septic system permitted if public sewer is available within 200 feet.) vti Installation will serve: Residence Commercial— Other FNumber of living units:� Number of bedr ms Character of sail to a depth of 3 feet: Water table depth SEPTIC TANK l�Type/Mfg �d-L Ge`,nc-f C4-4- Capacity` No. Compartments .: - PKG. TREATMENT PLT. ❑ '- � -� - Method of pi;posaf � i Distance to nearest: Well Foundation 1Property Line SLEACHING LINE No. & Length of lines fit) 1111 Tptal length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line i SEEPAGE PITS i I Depth Size Number I SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ i �l hereby certify that I have prepared this application and that the work wi11 be done in accordance with San.Joaquin,county ordinances, state laws, and t rules and regulations of the San Joaquin Local Health Di1trict. - Home owner or licensed agent's signature certifies the following: 'T'tertify thatlin the performance of the work for whichthis 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." T e applicant must c for all requir in pections. Complete drawing on reverse side. �] t t Signed X -- - e: Date: F R DEPARTMENT USE ONLY Application Accepted by Date Area F r_ Pit or Grout Inspection by . Gu;. Final inspection by �t,�, ,�.,,.�,y,-f� ��':� Date ji Additional Comments: fi 1 El Stk 466-6781 11 Loci 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Pefmit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 j F. INFO FEE AMOUNT DUE AMOUNT.REMITTED CASH RECEIVED 8Y DATE PERMIT NOEH 14-28 . r�EH 13-24 MEV.7/k 5)