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i APPLICATION FOR PERMIT + ,! SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) t 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 v rtf h kl 1f4v City Lot Size PM Owner's Name rAddress Phone Contractor 4� Address License No. '-, Phone tfv� TYPE OF WELL/PUMP: �I NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE j FOUNDATION AGRICULTURE WELL. OTHER WELL PITS/SUMPS ,r 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 F1 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.i`of Pump H.P. State_Work Done Well Destruction ❑ Well Diameter Sealing.material�ltop 50')� tt Depth Filler Material IBelow 5b'1;4 f TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/A-DDITION I I DESTRUCTIO (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial— Other"'"'-'" - \. V� Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK LIType/Mfg Capacity No. Compartments PKG. TREATMENT PLT- ❑ I� I Method of Disposal Distance to nearest: Well Foundation Property.Line LEACHING LINE ❑ No. & Length of lines 4Total length/size FILTER BED C] Distance to nearest: Well Foundation Property-Line SEEPAGE PITS 11 Depth Size _ Number SUMPS ❑ Distance to nearest: Well Foundation Property Line \ DISPOSAL PONDS ❑ Il I hereby certify that I have prepared this application and that the work will he done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the Sand 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 fol wing: "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 a The applic n I for all required inspections. Complete drawing on reverse sioe. Signed X Title: 04A Date: `` Fi6A)EPARTMENT USE ONLY Application Accepted by ! Date -_- Area Pit or Grout Inspection by )�. Date Fin I Inspection by - Date Additional Comments: G '� - ❑ Stk 466-6781 ❑ di I�369-3621 ❑ Manteca 823-3164 0 Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.,, C�CA 01 i 13 GF , fl i FEE AMOUNT DUE A OUNT REMITTED CK It CASH RECEIV 13Y DATE PE MIT'NO. INFO +,EH EH t4-2lS IREv.t i n 51 �