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_ APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELiON 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.599 for sewage or No. 1862 for well/Dump and the Rules and Regulations of the San Joaquin Local Health District. Job Addressy 1 1 0-7,<0 �J, � J` I /) �jt Cityt�`y-� '"`�` /�L^tot Size. PM Owner's Name16C-6"r-7 do, �;T k1c ' Ftltlress I`O r '-' 'v• 1 hone VL—� Contractors Address License No. Phone 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 PRS/SUMPS _ r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS -❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Weil Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ["1 Public ❑ Other ❑ 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 D ne Well Destruction ( Well Diameter Sealing Material Itop 50'1 O Depth Filler Material(Below 50'1 J TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION ( I DESTRUCTION I I Mo sep6GAystern 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 Cl Type/Mfg CapacityNo. Compartments r, PKG. TREATMENT PLT.O Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING UNE Cl No. 8 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS I] Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 California." The applicant mus11 }or all required inspections. Complete drawing on reverse side. (1 / Signed XXi!t �z G,G GnsL- -y Yr.'s'/C�j,•C�f'tle:) d h' ate: 4 V e _ ��, FOR DEPARTMENT USE ONLY CIOApplication Accepted by �' Date 4t.Area— Pit or Grout Inspection by Date � Final Inspection by Date ✓ V Additional Comments: ❑ Stk 4W-6781 -- ❑ Loth 369-3621 ❑ Manteca 823-7100 ❑ Tracy 835-6385 Applicant - Return a6 copies to: Environmental Health•P-errnit/.Sgrvicea 1601 E. Hazehon Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT OUE AMOUNT REMITTED H RECEIVED BY DATE PERMIT NO. �,. EH 1124(REV.i r xrS1 EH 14-m