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APPLICATION FOR PERMIT " SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED OT 72`{Z �. '��f.[�C-�. :A-r1E1: (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health Oistrict 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 L City Lot Size PM Owner's Name 612AZA Address /72 �� E• M Phone Contractor Address License No. dZ Z113 Phone TYPE: OF WELL/PUMP: NEW WELL WELL REPLAC15MENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ I DISTANCE TO NEAREST: SEPTIC TANK ME!P, SEWER LINES DISPOSAL FLD. llt f, PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �. r ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private r%Gravel Pack ❑ Tracy Type of Casing s/10&1 Specifications ❑ Public (] Other F1 Delta Depth of Grout Seal n1)t7L Type of Grout�7C)/7� N �G Irrigation --.Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material stop 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 111 REPAIR/ADDITION I 1 DESTRUCTION I I (No septic system 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 ❑ Type/Mfg Capacity No. Compartments 4I. PKG. TREATMENT PLT. ❑ Method of Disposal `s Distance to nearest: Well Foundation Property Line rfi LEACHING LINE ❑ No. & Length of lines Total length/size j FILTER BED ❑ Distance to nearest: Well Foundation Property Line ! SEEPAGE PITS I I Depth Size Number SUMPS Li Distance to nearest: Well Foundation Property Line x 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, 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 Calif rnia." The appli ant m st call for all r uir in�spectiorts/complete drawing on r verse side. q p Signed X < v �� [ Title: Date: C�-:� "<1 Cl F RtDEPARTMENT USE ONLY Application Accepted by 2) Date Pit or Grout inspection by Date Final Inspection by Dat Additional Comments: ❑ Stk 466-6781 1 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applica rn II copies�t'o.,Envir mental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 I r FEE CK INFO NT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PEItMIT'NO.F f • EH 13-24(REV.�ir<51 ` EH 14-2e If