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s APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT R 1601 E..HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 . 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 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. City��r -- Job Address `r 1 Lot Size PM Owner's Name Addressf Phone Contractor � Address � �°1�� l 14S License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ f WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑' SYSTEM REPAIR ❑ OTHER ❑ V� , DISTANCEO T: SEPTIC TANK SEWER LINES . DISPOSAL FLD. PROP. LINE FO AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBL CONSTRUCTION SPECIFICATIONS 'i ❑ Industrial ❑ Open Bottom ❑ Manteca Dia,o cavation Diafof Well Casing r . ❑ Domestic/Private ❑ G ravel,_Pack.C T.racy_T.ype of_Casing Spg!;fjCations.__ �- ❑ Public -1Other' 0 Delta Depth of Grout Seal i3e of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by ' Repair Work Done ❑ Type of Pump H.P.. State Work Done Well Destruction ❑ Well Diameter Sealing Material-`(top 501 Depth '- Filler Material (Belo5.w') \ i i TYPE OF 5EPTI1; .W_Of3K; NEW INSTALLATION ❑ REPAIR/ADDITIONDESTRUCTION_❑. (No-septic syster'n permitted if public sewer is ..# available within 200 feet.) Installation will serve: Residence— Commercial_ Other = Number of living units: 4 Nu>;ber of bedrooms f s Character of soil to 6 i`depth of 3 feet: - Waterltable depth SEPTIC TANK ' IJ Type/Mfg Capacity<' No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal � Distance'to=nearest: Well a"' � Fouiidati'on max. '� __.. Property LitieT� LEACHING LINE Nal & Length6f4ines _' .j{. _ _Tal length/size 1 FILTER BED El Distance to nearest: Well j... Foundation Property;Line i t t OL SEEPAGE PITS {' Depth i Size 1 Number I SUMPS d Distarice to nearest:L` Well Foundation �f)t 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, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or.licensed agent's signature cefEifies the following: "I certify that in the performance ofrthe 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 Califorrna!;-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 California." } The applicantmI call for all required-inspections. Complete drawing on reverse side. Signed X f+ V l.�1 (�.. Title: r "' Date: ' R DEPARTMENT USE ONLY I . Application Accepted by Date -26ZU - � Area I Pit or Grout Inspection by Date Final Inspection by Date,' Additional Comments: f I ❑ Stk 466-6781 ❑ Lodi 369-3621 O Manteca 823-7104 ❑ Tracy 835-6385 i Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY a DATE PERMIT"NO. INFO CASH + EH 1&24lREV.tia57 - i EH 14-26 f - - 1