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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 1 YEAR FROM DATE.ISSUED_ r i (Complete in Triplicate) 7a Z 7i { 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. , Job Address City Lot Size PM I Owner's Name q1, Address Phone Contractor's Name 4& icense No. Phone -' TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION d PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE r -FOUNDATION " ' AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial D Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel 3Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other•y ❑ Delta--_.Depth of Grout Seal Type of Grout ❑ Irrigation Approx. Depth` ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. r State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') 6� f Depth Filler Material (Below 501 _1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is 1 available within 200 feet.) 4 Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms f x Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK 6 T e/ f9 ""Capacity No. Compartments PKG. TREATMENT PL ! Method of Disposal Distance to nearest: Wei Foundation Property Line t LEACHING LINE AN=ph�( s k� ' Total IengtF/i $FILTER BED n crest. Well Foundation- - -Property.-Line.. t SEEPAGE PITS Depth a�� SizeT Number SUMPS ❑ ,Distance to nearest: Well _ ..Foundation Property Line Z DISPOSAL PONDS ❑ k 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 certifyAhat 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 cbmpensation laws of California."Contractor's hiring or sub-contracting signature certifies the following wcertify that in the performance of the work for whldh this permit is issued,I shall employ persons subject to workman's compensa- tion las of Californi 4 i The applicant m s a for all required inspections. Complete drawing on rev side.. J I Signed ) Title: � bate: r � FOR DEP T E USE ONLY Application Accepted by Date r� Area Z_ Pit or Grout Inspection by 3 DatJ � ' 'Final Inspection by � Date r _ Additional Comments: `` r . ❑ Stk 466-fi781 ❑ Lodi 369-3621 '❑'+Manteca)823-7104 ❑ Tracy 835-6386 i Applicant- Return all capias to: Environmental Health Permit/services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE i INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT`NO. Ii * EH 13-24 EH 13-26 MEV.10/831 L 1