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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON 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 with San Joaquin County Ordinance No.549 for sewage or No. 1851 for well pump and the Rules and Regulations of the San Joaquin { Local Health District. 1 i Job Address lJ � - City �" Lot Size 5-f ✓ PM � Address �` \' ` Phone Owner's Name � + - Contractor's Name13 se No. } Phone TYPE OF WELL/PUMP: NEIN WELL ❑ WELL REPLACEMENT 11 DESTRUCTION ❑ Ik PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ I 0THER El DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. i PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ industrial ❑ Open Bottom ❑ Manteca pia. of Well Excavation ,Dia. of Well Casing El Domestic/Private ❑ Gravel Pack "❑Tracy x - Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout x.�-• urface Seal Installed b El Irrigation --Approx. Depth ' ,![E-Eastern S Y Repair Work Done ❑ Type of Pump H.P. State Work Done ! Well Destruction ❑ Well Diameter Sealing Material [top 50'1 I I t Depth Filler Material [Below 50') �.. TYPE OF SEPTIC WORK: NEW INS7_0 ION E3REPAIR/ADDITION El DESTRUCTION El '(No septic system permitted if public sewer is ;.� available within 200 feet.) 0 Installation will serve: Residence Iommercial_ Other 1 Number of living units: Number of bedrooms ,. Z # i Character of soil to a depth of 3 feet: 0= Water table depth SEPTIC TANK ❑ Type/MfgIV Capacity No. Compartments PKG. TREATMENT PLT. ❑ r,•�' —-.. —� — - —� �- ,Method of Disposal /tri Distance to nearest: Well t-W Foundation 0 Property Line 11 f LEACHING LINE 111No. & Length of lines Total lengthlsize I FILTER BED ❑ Distance to nearest: Wall Foundation .� Property Line ` SEEPAGE PITS S>Depth Size Number SUMPS ❑ Distance to nearest: Well - Foundation Property Line 44 12 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 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:"1 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." l The applicant must gaLfor all required ' ctions. CompI t dr ing on reverse side. Signed Title: Data: ti FOR DEPARTMENT USE ONLY gy " .- Application Accepted by T � Date Area�� Pit or Grout Inspection by 5—r Date Final Inspection by Date fAdditional Comments: L Lf0 ' ❑ Stk 468-6781 ❑ Lodi 369-3621 O Manteca 823-7104 ❑ Tracy 835-6385 i Applicant- Return ail copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 If FEE " AMOUNT DUE AMOUNT REMITTED SASH RECEIVED BY DATE PERMIT`NO. INFO -y X70 /� J a EH 13-241REv.10183} ! Ly�t EH 14-26