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t APPLICATION FOR PERMIT ° SAN JOAQUIN LOCAL HEALTH DISTRICT Z, 1601 E. HAZEL T ON AVE„ STOCKTON, CA Telephone (2091gR1 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 F 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 t -/7 City—AAn4�1 rQQ Lot Size PM ?owner's Name J—os� +� r V e ev— --- Address -Sq y"E Phone contractor f' S' �� Address 4--77 e License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Cl PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL R WELL PITS/SUMPS INTENDED USE TYP L PROBLE ONSTRUCTION.SPECIFICATIONS s -0 Industrial : ❑ Open Bottom eca Dia. of Well Excavation Dia. of Well Casing \� ❑ Domestic/Private ❑ Gra ck ❑ Tracy Type of Casing Specifications _ {"1 Public Other � Cl Delta De i Grout Seal Type of Grout i I kngation --.Approx. Depth l l Eastern Surface Sea tolled by _ Repair Work ne ❑ Type of Pump H.P. �' tate Work Done Well Destruct) p Well Diameter Sealing Material Itop_50'I Depth t Filler Material (Below 50'1 � — TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIR/ADDITION I I DESTRUCTION available.within,200 feet.) Installation will serve: Residence Commercial_ Other _ Number of living units: Numher of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments I PKG. TREATMENT PLT. ❑ 1" Method of Disposal Distance to 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 I Depth Size Number SUMPS 0 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, stat 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 issue I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractors 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 must call for all required inspections. Complete drawing on reverse side, p Signed X � �1 Title: e r' Date: FOR DEPARTMENT USE ONLY Application Accepted by Date �Z z. Area 3 Pit or Grout Inspecti y Date Final Inspection by 6-el, Dated Additional Comments: ❑ Stk 466-6781 ❑ L 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT"Np. INFO +.EH 1 -24(REV. i H 5) ' EH 144"28