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— ,,. APPLICATION FOIFMIT 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. 1962 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. City Lot Size PM ` Job Address �qS1 Address Phone Owner' Name 0 s ,�'.�,� , - m ��- ti� Address t License No Phon Contractor e TYPE OF WELL/PUMP: NEW WELL.,D WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION ❑ � S�STEM REPAIR ❑ .OTHER ❑ c DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL, OTHER WELL !r PITS/SUMPS _. I INTENDED USE TYPE OF WELL PROBLEM AREA "CONSTRUCTION SPECIFICATIONS C] Industrial ❑ Open Bottom r---d-Manteca ] Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of'Casing Specifications F1 Public ❑ Other Cl Delta L pth of GroLt Seal Type of Grout I 1 Irrigation --Approx. Depth L l Eastern rface Sea1_,Installed.by_ ! Repair Work Done C7 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material [tap 50') ^ r Depth Filler Material (Below 501' TYPE OF SEPTIC WORK: NEW INSTALLATIONX REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is `/ available within 200 feet.) I Installation will serve: Residencex Commercial"� Other Number of living units: Number of bedrooms aracter of soil to a depth of 3 feet: Water table depth ChCapaci SEPTIC TANK ❑ Type/Mfg F' ty No. Compartments PEG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE .V No. & Length of lines �. - -'_ Total length/size FILTER BED ❑ Distance to nearest: Well .0 Foundation Property Line r SEEPAGE PITS b ( I Depth Size � Number Y SUMPS '� ' LI Distance to nearest: Well d Foundation ° Property Line DISPOSAL PONDS '` ❑ } r I hereby certify that I have prepared this application and that t'he 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:`--"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 a e must call f all required inspections. Completdrawing on reverse side. ic Date: Signed X r F0 DEPARTMENT USE ONLY Application Accepted by Date Area "7 Pit or Grout Inspection by Date Final Inspection by Dat Vi, Additional Comments:• - El 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 Q� r. FEE AMOUNT DUE AMOUNT REMITTED CA RECEIVED ElY DATE PERMITND. C\1` F INFO r EH 13-24(REV.i H 5) !f� 1 EH 14-26