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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT r 1601 E. HAZE 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. 1 Job Address 1( 5o ��-J1/�1 City V Lot Size PM Owner's Name7r 7Y l.t a Address Pf7on Corntracto License No. Phone TYRFOF WELL/PUMP: NEW'WELV❑ LL REPLACEMENT ❑ DESTRUCTION ❑ r�w� —.--...______PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ �f,„ 1/1 DISTANCE EAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE O FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE ELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS-- 71 Industrial ❑ Bot ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 4 Domestic/Private Gravel Pack* Tracy Type of Casing Specifications 1-1 Public ❑ Other ❑ Ita Depth of Grout Seal Type of Grout _ i I Irrigation --Approx. Depth i I East Surface Seal Installed by Repair rk Done ❑ Type of Pump H. State Work Done_ W estruction ❑ Well Diameter Sealing aterial Itop 50'1 Depth Filler Material (Below 50') f TYPE OF SEPTIC WORK: NEW INSTALLATION (1 REPAIRIADDITION DESTRUCTION l 1 INo septic system permitted if public sewer is available within 200 feet.) F Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments e PKG. TREATMENT PLT, ❑ Method of Disposal Distance to nearest: Well Foundation Property Line - 1 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line ? SEEPAGE PITS I I Depth Size Number SUMPS 0 Distance to nearest: Well. Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the.workc will be done in accordance with San Joaquin county ordinances, state laws, and l 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 ormance of the work for which this permit is issued,i shall employ persons subject to workman's compensa- tion laws of California." t The applicant m t for all eq— inspec ons. Complete drawing on raver a side. +- Signed X Title: tAl pate: r A FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Um _ Stk 466.6781 ❑ Lodi 369-3621 ct9 Manteca 823-7104 ❑ Tracy 835-6385 —~ r pplicant Return all copies to: Environmental Health Permit/services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ►�+� ! FEE INFO AMOUNT DUE AMOUNT REMITTED AS�H RECEIVED BY DATE PERMIT NO, + EH 13-21(REV. /x 5) I EH 11-28 4 n