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APPLICATION FOR PERMIT j SAN JOAQUIN LOCAL HEALTH DISTRICT l 1601 E. HAZELTON AVE., STOCKTON, CA i 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 F Local Health District. i a 3b C��1'1S' , City :r Lot Size Job Address PM h - - " 4 Y! // Phone Owner's Name Address ` l � Contractor's Name License No. 3 Phone (� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REP ❑ OTHER Q DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE. i FOUNDATION GRICULTURE W OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL��±PROBL'EM AflFA TRUCTION'SPECIFICATIONS . ❑ Industrial ❑ Open Bottom 1 ❑ Manteca Dia. of We avation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ? ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Ea rn Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (NosbpticYsh nem emitted if public sewer is avaInstallation will serve: Residence'L Commercial_ Other ' Number of living units: /-- Number of bedro ms -- w 41 Water table depth Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. F-1let of Disposal f t Distance to nearest: Well Foundation Property Line "F LEACHING LINE I No. & Length of fines Total length/size M z 1 FILTER BED ❑ Distance to nearest! Well Foundation Property;Line, •�a 'fes 1 SEEPAGE PITS ❑ Depth I Size tom. Number ' SUMPS Distance to nearest:. Well _ Foundation� Property Line 41-31-0 �J 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 Vicensed 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 sucPrnanner as to become subject to workman's com"nsation•laws-of-6alrfornia.-Contractor'"s'hiiing ar sub contracting signature certifies the following ,'I certify that in,the performance of the work for whlcF this permit is issued,I shall employ persons subject to workman's compensa- tion laws of Ca0or" &.-JO Y v i 3 The applicant II for 11 required inspections. Complete''dr*awing on reverse side. Yt Y- "_-:-t '-Date: Signed -^47�41e: � `�� FOR DEPARTMENT USE ONLY Date. rf 6 Area f Application Accepted by ; 1� pIV Pit or Grout Inspection by4r Date N't* Final Inspection by uy /T�� Date=�. - . , r t ;, Additional Comments: j { ❑ Stk 466-6781 ❑ Lodi 369-3621 Q Manteca 823-7104 ❑.Trapy,835 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 - -4_- �. FEE AMOUNT DUE AMOUNT.REMITTED ECCA"S RECEIVED BY DATE PERMIT'NO.INFO —4[REV.10/a3F '�EH 1426 k i