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APPLICATION FOR PERMIT SAN .10AQUIN LOCAL HEALTH DISTRICT � � �� 1601 E. HAZEL T ON AVE., STOCKTON, CA /�-7c Telephone (209) 466-6781 `T PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) �7 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. � Joh Address y Lot Size� r rr Cit t—A-I-AroP 2d X 106 PM - Owner's Name LC 1 Ct�Q'Atfdress t `zv Ph... Contractor i Address ��.�a r/�f �l �'C ed-Dcense No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTAN E TO N TIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDA AGRICULTURE WELL OTHER SUMPS INTENDED USE TYPE OF WELL PROBL STRUCTION SPECIFICATIONS T LJ Industrial IDOpen B ❑ Manteca Ria- of Well xc Dia. of Well Casing El Domestic/Private ravel Pack ❑ Tracy Type of Casing tions ll Public ❑ Other F-I 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 Done Well Destruction 0 Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION (No septic system permitted if public sewer is vailable 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 PKG. TREATMENT PLT. ❑ 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 L1 Distance to nearest: Well Foundation Property tine 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, 1 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 cortify 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 ail requir inspections. Complete drawing on reverse side. Signed X Title: Date: FOR DEPARTMENT USE ONLY Application Accepted byt369-3621 '� Date �-�� Area_ Pit or Grout Inspecti Date Final Inspection b `' ' Date��"� -� Additional Comments: ❑ Stk 466-6781 odi ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEEINFO AMDUNT QUE AMDUNT REMITTED C K H RECEIVED BY DATE PERMIT NO. a.EH t3-24IAEV.f/145) EH 14-26 6