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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/of 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. _ I.,,, ^ Job Address _— � L�- �V Z- City Lot Size PM Owner's Name / �� Address _ Phone rr Contractorl�l�S S�/a Address License No. Phone -3�f TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Q DESTRUCTION ❑ PUMP INSTALLATIONN fQkF QSYSTEM 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 ❑ Open Bottom ❑ Manteca Dia. ot.Well Excavation Ilia. of Well Casing Domestic/Private ❑ Gravel Pack 171Tracy Type of Casing Specifications FI Public 17=1 Other I1 Delta Depth of Grout Seal i Type of Grout I I Irrigation —Approx. Depth l I Eastern Surface Seal Installed by I Repair Work Done ❑ Type of Pump H.P. State Work Done LFT/�jE\ Well Destruction ❑ Well Diameter Sealing Material #top 501 Depth Filler Material {Below 501 1 AZjfQNaF TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIWADDITION i I DESTRUCTION l I i(No septic system permitted if public sewer is %available within 200 feet.) Installation will serve: Residence Commercial— Other Number of living units: Number of bedrooms �-a Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No.'.Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance Property. .k Line LEACHING SINE ❑-:No. & Length of lines Z ? Total length/size FILTER BED ❑'distance to nearest: Well Foundation Property-Line SEEPAGE PITS I I Depth Size Number SUMPS L] Distance to nearest: well FoundationProperty Line DISPOSAL PONDS ❑ f s� I hereby certify that I have prepared this application and.that the work will be done in accordance with Sari J oaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Heafth'_bistrict. -- 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 bf the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant equine ti ns. Complete drawing on reverse'side: Signed XT 4 itle: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date A 0 ' Area Pit or Grout Inspection by Date Final Inspection by Date! - f Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK 9 RECEIVED BY "cot,, PERMIT NO. + EH 13-24 IREv.rix 51 ) ��-y r_ EH 14-26 ll co