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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 t. (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. �. e J�/O 3 � •r itl� City Lot Size` �+ PM Job Address - Owner's Name Address T ._ Phone Contractor's Name License No. 3 Phone �8 Z I TYPE OF.WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑• DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ j I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES , DISPOSAL,FLD. PROP. LINE FOUNDATION AGRICULTURE+WELL OTHER.WELI � PITS/SUMPS INTENDED tUSE TYPE OF'WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS El Industrial ❑ Open Bottom, E3 Manteca..+ Dia. of Well Excavation Dia, of Well Casing ❑ Domestic/Private ❑ Gravel Pack ©~Tracy Type of Casing Specifications D �` ❑ Public , ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern.-' Surface Seal Installed by O Repair Work Done ❑ Type of Pump `" H.P. State Work Done + Well Destruction ❑ Wall,Diameter Sealing Material (top 50') W 'Depth Filler Material (Below 501 TYPE OF SEPTIC MRK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is r I iavailable within 200 feet.)` Installation will serve: Residence Commercial_ Other Number of living units: --L— Number of be rooms_-_. : /ew (.- Character of soil to a depth of 3 feet: _ "-� /1�n- Water table depth SEPTIC TANK Type/Mfg ��+� P4 Capacity /�cido No. Compartments PKG. TREATMENT PLT. ❑ ,Method of yDisposal Distance to nearest: Well 50 Foundation Property Line {D LEACHING LINE No. & Length of lines r Totallengthlsize �'� r `' FILTER BED ❑ Distance to nearest: Well —Foundation ,L Property Lined SEEPAGE PITS, . :-- —Depth- Size. Number SUMPS ❑ Distance to nearest: Well 1 rJ� ..Foundation Property Line DISPOSAL PONDS ❑ 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, I 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 mu call for all required inspections. Complete drawing on reverse side. �� Signed Date:f0 S Title: �Z . FOR DEPAR MENT USE ONLY f Application Accepted by Date r f'Area Pit or Grout Inspection by Date _Final Inspection by Date _ Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385M T Applicant- Return all.copies to. Environmental Health Permit/-Services 1601-E. Hazelton-Ave., P.O. Box 2000, Stk.,CA 95201- kFEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO r + EM 113-254 EH 1426 IREV.10/831 S. Vs--,'R 4 1^t,0 -