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( APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT f 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED r (Complete in Triplicate) I 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 ri Local Health District. Job Address � � City Lot Size 7F0 PM Owner's Name . F Address ' Phone- Contractor Address L . 0 Phone ontract License No _ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION'Ll SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE t FOUNDATION AGRICULTURE WELL - OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS l ❑ Iridustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private r L] Gravel Pack ❑ Tracy Type of Casing Specifications [-I Public f }! ❑ Other ❑ Delta Depth of Grout Seal Type-of Grout _ I 1 Irrigation __Approx. Depth l 1 Eastern Surface Seal Installed by - I Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 50') Depth Filler Material IBelow 50'1 ^� TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION /DESTRUCTION [ I (No septic system permitted if public sewer is. J j available within 200 feet.) i Installation will serve: Res'dence Q�Commercial Other r Number of living units: Number o ed Dome — r Character of soil to a depth of 3 feet: — �- a Water table depth SEPTIC TANK L�Type/Mfg 6'j 1 Capacity No. Compartments r Method of Disposal PKGI TRPiTMENT PLT. ❑ r p Distance to nearest: Well Foundat ora\ (I Property Line LEACHING LINE R---No. & Length of lines `Y I- f.,Total length/size FILTER BED ❑ Distance to nearest: Wells -`Oat/ Foundation! 1 13 e'rty Line r �e G/1 Number � 1 SEEPAGE PITS M"Depth .� �1 Size N S040S L.7i Distance to nearest: We[IILL � Fou ion �� Property Line ry DISPOSAL PONDS ❑ ra i-.. .c_• ♦ ` I hereby certify that I have prepared this'application and that the work wi(I-b"3"8one m accordance with San Joaquin county ordinances, state.laws, and rules'and regulations of the San Joaquin Local Health District. C 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 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 applicant must call for all r uir inspections. Complete drawing on reverse side. t7 ( FSig ned X Jitle:.^�r C Date: I �IvU�.ctry,1 J FOR DEPARTMENT USE ONLY i Application p y i n Acce ted b � Date Area I 6itr Grout Inspection by _ to nal Inspect Additional Comments: ❑ Stk 466-6781 ❑ L# 369-3621 ❑ 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 f FEE AMOUNT DUE AMOUNT REMITTED SH RECEIVED BY DATE PERMIT N0. INFO + EH 13.24 IREV.t/n 51 10—PJ /D/ EH 14-2e