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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) .` in Local Health District for a permit to construct and/or install the work herein described.This application is Application is heleby made to the San Joaqu 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. A' Lot Size PM �I E fi Job Address fty "._ �� 2crPhone ' Owner's Name Address r n `J Address JrG License N 3 � 2 Phone Contract rLoc � \ve TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Ll DESTRUCTION DESTRUCTION \ , PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ O DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE i FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing C1 industrial F1 Open Bottom ❑ Manteca Dia. of Well Excavation Type of Casing Specifications r ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy T of Grout ❑ Public ❑ Other, III Delta Depth of Grout Seal Type ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Wel! Destruction ❑ Well Diameter Sealing Material (top'501 Depth 'Filler Material (Below 50T . TYPE OF SEPTIC WORK: NEW INS- ALLATION ❑,`:REPAIR/ADDITION DESTRUCTION ❑ (Nos ptic ith tem permi(emitted if public sewer is availaIl installation will serve: Residence X Commercial_ Other Number of living units: Number of bedrooms Water table depth Character of soil to a depth of 3 feet: SEPTIC TANK D}' TypelMfg r a Capacity L?O " U[ No- Compartments goo Method of Disposal PKG. TREATMENT PLT. F'I / Distance to nearest: Well Foundation Property tine LEACHING LINE RF No. & Length of lines a — ' Total length/size r / G [ Q Y Z FILTER BED LI Distance 'to nearest: Welk_ �_ Foundation r Property tine_�: - - Side SEEPAGE PITS ?f Depth Number SUMPS Ll Distance to nearest: ! Well� Foundation Property Line—�S DISPOSAL PONDS Lj 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. llowing: "1 certify that in the performance of the work for which this permit is issued, I shall not Home owner or licensed agent's signature certifies the to ' workman's compensation laws of California." Contractors hiring or sub-contracting signature employ any person in such manner as to become subject certifies the following: "I certify that in the performance of the work for which this permit is issued,k shall employ Persons subject to workman's compensa- tion laws of California." The applicant mus call for all r, ired inspections. Complete drawing on never sid� 1 `, Date:-Q_ Signed X ' Title: t,` FOR DEPARTMENT USE ONLY I Date � � Area Application Accepted by � � / [ � Pit r Grout Inspection by C Date_ �IFin�nspoction by Date Additional Comments: ❑ Stk 466-6761 L] Lodi 369-3621 EI Manteca 823-7104 El Tracy (335-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 CK RECEIVED BY DATE EMT- # FEE AMOUNT DUE AMOUNT REMITTED CASH INFO t r EH 13-2a IREV,I: ........... EH 14.76 C� _