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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT i 1601 E. HAZE T ON AVE., STOCKTON, CA � I Telephone (209) 466-6781 PERMIT EXPIRES 1YEAR 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- /— t Job Address "� �� City Lot Size, PM ��D � I Owner's Name _AddressK� Phone , ' Contractor;. �ytJ Address License No. Phone �— 't — TYPE OF�WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTtON [I PUMP INSTALLATION ❑ SYSTEM REPAIR-11 OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES -DISPOSAL FL-D.. PROP. LINT= FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPSJ_ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS " ❑ Industrial—. —�_[J_Open-Bottom_C]-Manteca,�.—Dia._of_Well-Excavation -- nia._of WellCasing_ ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F] Public C1 Other ❑ Delta Depth of Grout Seal Type of Grout _ I I Irrigation --Approx.!Depth l 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 Filter Material (Below 50'1_ TYPE OF SFPTtC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I I DESTRUCTION (No septic system permitted if public sewer is I I ' vailable within 200 feet.l 0 I Installation will serve: Residence Commercial— Other I Number of living units: Number of bedrooms t3 ' , Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfgi tyNo. Compartments PKG. TREATMENT PLT. ❑ VMethod of Disposal Distance to nearest: Well Poundation,---.^---PFoperty Line (11>I LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to_nearest: WellFoundation Property Line SEEPAGE PITS 11 Depth Size _ Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 Joaquirn Local Health District. Home owner or licensed agent's signature certifies the follpwing: "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," 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 3 The applicant us all for ail re d iCmplete drawing on reverse side. ^� Signed X Title: Date: FOR DEPARTMENT USE ONLY Application Accepted ' ' ` Date ^� Area Pit or Grout Inspectioby `l Date Final Inspection by Date Additional Comments: �� 1 err l <ir !'J�t7` V/14/ ❑ Stk 466-6781 ❑ VZ 21 ❑ Manteca 823-7104 ❑ Tracy 835-6585 Applicant - Return all co " se'r�m ntal ealth Permit/Services 1601 E. Hazelton Ave„ P.O. Box 2009, Stk., CA 95201 FEE INFO A DUE AMOUNT REMITTED C RECEIVED BY DATE PERMIT*NO. i ♦ EH 13-24(REV.riK57 EH 10-29 A'G c9 J 8 (p