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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE',TON AVE., STOCKTON, CA 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 withSanJoaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. �- =n� Job Address .- d City Lot Size 1 PM r Owner's Name U/11a)l Address ` ` [r• �.--tai Phone O �lst� Address License No. � �� Phone Contractor - TYPE OF_WELL'/PUMP:` -N W£LL.❑ ELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE I, GR FOUNDATION- AICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ industrial 4 ❑ Open Bottom ❑ Manteca r Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑•Gravel Pack ^>w ❑ Tracy k Type of Casing Specifications I`l Public '` ' Cl'Other '` l7 Delta I Depth of Grout Sea! Type of Grout 11 Irrigation }., g._Approx. Depth H Eastern, Surface Seal Installed by t' Repair Work Done ❑. Type of Pump'—. H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l l DESTRUCTION € I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial;_ Other Number of living units: Number of bedrooms f i Character of soil to a depth of 3 feet: Water table depth i SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well ' Foundation Property Line e LEACHING LINE . ❑ No. & Length of lines ° Total length/size FILTER BED ❑ Distance to nearest: Well t Foundation Property Line SEEPAGE PITS 1`1" Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property_Line DISPOSAL PONDS ❑ _ J I hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin county_ordinances, state laws, and 5 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."Contractors 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 requi re0onspections. Complete drawing on reverse std/ 01 Signed X - Title: Date: FOR DEPARTMENT USE ONLY � Application Accepted by � .� Date r_ R� Q Area� � �� pp�� Pit or Grout Inspection by Date Final Inspection by Date dditional Comments: Stk 466-6781 ❑ Lodi 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 FEEgMDt}NT DUE AMOUNT REMITTED C RECEIVED 6Y DATE PERMIT'NO. # _ INFO + EH 1324IREV.1./m51 �� ✓ V (� EH 1428 Y