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' APPLICATION.FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL I ON AVE., STOCKTON, CA Telephone (209) 466-6781.E PERMIT EXPIRES 7 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. 18.62 for well and the Rules and Regulations of the San Joaquin Local Health District. rte( ! 7(/ ,l�r tl/�f'"I � �: !- f City Lot Size PM.. Job Address^ Owner's!Name Address j .33 r)' Phone V� �� • 7 y r ' r<.�� iJ �a 1 License No.' ` Phone S Contract Address TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 ❑ Industrial El Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ElPublic ❑ Other EJDelta Depth of Grout Seal Type of Grout ❑ Irrigation _ Approx. Depth ❑ Easterner^""""-"Surface Seal Installed by Repair Work Done ❑ Type of Pump j H.P. State Work Done Well Destruction Ll Welt-Diameter Sealing.Material (top 50'1 Depth Filler Ai�a'ten6l (Below 50'1 S TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION 13 (No septic system permitted if public sewer is J ` available within 200 feet! r � _ Installation will serve: Residence Commercial= Other U Number of living units: J_ Number of edrooms ' - "� �I ® p Character of soil to a depth"of 3 feet: - Water table depth �! - { SEPTIC TANK I :.Type/Mfg 4 Capacity��6 No. Compartments ;! ---/---Method of D'sposaI PKG. TREATMENT PLT. El r,. Foundation `I0 Property Line 5 l� Distance to nearest: 'Well -- LEACHING LINE Rr No. & Length of lines � �� Total length/size IN6 FILTER BED ❑ Distance to nearest: Well Foundation /4 Property Line S 1� SEEPAGE PITS Depth Size Number SUMPS C] Distance to nearest: ' Well Foundation _Property.Line. I DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that-the-work-.willbe-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:"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 ust call f all required inspections. Complete drawing on reve icie. Q r Signed Title: 1 Qate:, SP s , FOR DEPARTMENT USE ONLY / Application Accepted by _ Date 2 Area—Q — ti t Date /f Pit or Grout Inspection by,2_ Date Final Inspection by Additional Comments: ❑ Stk 466-6781 ❑ L i 369 3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 � ?� Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box Stk., A 1 /d FEE �� INFO AMOUNT DUE AMOUNT REMITTED ' CASH RECEIVED BY DATE PERMIT NO. dt + EH 13-24{REV"1/5 5) EH 1426