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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELI ON AVE., STOCKTON, CA . r Telephone (209) 466-6781 I PERMIT EXPIRES 4 YEAR FROM DATE ISSUED i �. . (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. c sS L ` + City. c Lot Size PM Job Address — �. L,Q„ Address 4 1A-, — Phone 3 — �-?4 Owner's Name � Contractor � Address License No. Phone TYPE OF WELLIPUMP: NEW WELL Ll WELL REPLACEMENT El DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS 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 ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout f ❑ Irrigation JApprox. Depth ❑ Eastern Surface Seal Installed by 1 Repair Work Done ❑ Type of Pump H-P' State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth IFiller Material (Below 501 t TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ 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 Water table depth Character of soil to a d of 3 feet: SEPTIC TANK Type/Mfg Capacity No. Compartments pth PKG. TREATMENT PLT. ❑ ! 'X 4— Method of Disposal Distance to nearest: Well Foundation 71 Property Line LEACHING LINE ❑ No. & Length of lines x j _ t Totai length/size I FILTER BED ❑ Distance to nearest: Weil Foundation {' Property Line r SEEPAGE PITS ❑ Depth Size 2 K.' Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 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 corn n`sation, ws 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." 1 The applicant must call for all requited inspections. Complete drawing on reverse side. }�Signed X�;?� ��` Title: Date:, FOR DEPARTMENT USE ONLY Application Accepted by Date Area 9� Pit or Grout Inspecti n by Date Final Inspection y �� Date '] U n. Additional Comments ❑ Stk 466-6781 ❑ Lodi 36.9-3621 ❑ Manteca 823-7104. El Trac83546385 Applicant- Return all copies to: Environmental Health Permit/Services 1 1 E. Hazelton Ave., P.O. Box 2009, Stk., CA 96201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT`N0. INFO -- + EH 13-241REV,1/85) EH 14.26 IL