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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA l 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-he'r'ein described. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for welU pump and the Rules and Regulations of the San Joaquin i Local Health District. �� L19 PM CityT Lot Size Job Address Owner's Name " � �/illddress �/ AA1 1 Phone j �J� / a'"5. �$ /Q UP �/( License No-, v ® Phone��1 Contractor/56AIk • � e-L� Addresa� NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ TYPE OF WELLIPUMP:. � PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 11 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing l ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation i Type of Casing Specifications ❑ Domestic/Private ❑ Grave! Pack ❑ Tracy Type of Grout n Public F1 Other ❑ Delta Depth of Grout Seal - 11 Irrigation —..Approx. Depth I 1 Eastern Surface Seal Installed by I Repair Work Done ❑ Type of Pump H P State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION i.A REPAIR/ADDITION l I DESTRUCTION (Nailabpticle system pein (fitet.ted if public sewer is Installation will serve:' Residence_ Commercial_ Other Number of living units: Number of bedrooms Water table depth Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments R Method of Disposal p\' PKG. TREATMENT PLT. ❑ Distance to nearest: Well Foundation Property Line k LEACHING LINE ❑ No. & Length of lines Total length/size f FILTER BED ❑ Distance to nearest: Well Foundation Property Line E l SEEPAGE PITS 11 Depth Size Number 1 SUMPS 0 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ t 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 ct to workman's compensation laws of California." Contractor's hiring or sub-contracting signature employ any person in such manner as to become subje 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 fo all required inspec• ns. Complete drawing on reverse side. -9-1 Signed i� Signed ^ Title: b,� ! [� Date. 6 7` r FOR DEPARTMENT USE ONLY Date — Area r Application Accepted by Final Inspection by Date Date Pit or Grout Inspection by ' Additional Comments: y ❑ Stk 466-6781 ❑ Lodi 369 1 ❑ Manteca 823-7104 ❑ Tracy�83 6385 S _ -713d qO Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO r EH 13-24 1REV.I/t3 51 3 . .EH 14-26