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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 u 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 welUpump and the Rules and Regulations of the San Joaquin Local Health District. Job Address � � / Gt1 ! � City Lot Size PM Owner's Name FM r t/iu ('&-.4 Addresslite Phone Y-41X36 Contractor's Name j .License No. 3Q Ell Phone 06f z?:F,?3 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ I F PUMP INSTALLATION Cl SYSTEM REPAIR C1 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. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Grave( Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout © Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by / Repair Work Done ❑ Type of Pump H.P. State Work Done QQ Well Destruction ❑ Well Diameter Seating Material (top 50') { Depth Filler Material (Below 501 �. TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.l 'Installation will serve: Residence b/ Commercial_ Other Number of living units:A_ Number of be roams S t Character of soil to a depth of 3 fe * Water table depth SEPTIC TANK Lr Type/Mfg� it+. Capacity No. Compartments PKG. TREATMENT PLT. 1-1 r 1 Method of isposal Distance to nearest: Well Fou dation Property Line � r LEACHING LINE & Length of lines d Total length/size 2-01 FILTER BED fistance to nearest: Well Foundation Property Line SEEPAGE PITS E-/Depth 2= Size (a a Number SUMPS ❑ Distance to nearest: Well L Foundation :161 Property Line DISPOSAL PONDS ❑ 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state arvs, vied 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 must f all required inspections. Complete drawing on reverse side. Q Signed X 1 Title: w Date:,Z ! FOR D ARTMENT USE ONLY Application Accepted by Data _—WArea Dit rGrout Inspection by ate Final Inspection by ate Additional Comments: ❑ Stk 466-6761 ❑ 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 INFO AMOUNT DUE AMOUNT REMITTED C K RECEIVED BY DATE PERMIV`NO. + EH 13-24(REV.141931 EH 1426 . CaD $S^39 !�