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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE 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. 1862 for well/pump and the Ryles and Regulations of the San Joaquin Local Health District. r 3 City Lot Size o ��PM Jab Address Owner's Name (_ Address �� U� ,v' / ' � — Phone r �. � - 3� �Contrac ria t aAddress r License No.TYPE OF WELL/ UMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTON PUMP INSTALLATION ❑. SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK -, .SEWER LINES DISPOSAL FLD. PROP. LINE tt FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS :. INTENDEDUSETYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout 5, ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done r Well Destruction ❑ Well Diameter Seating Material (top 50') Depth ler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ EPAI ADDITION 27DESTRUCTION © (No septic system permitted if public sewer is available within 200 feet.► � Installation will serve: Residence Commercial Other Number of living units: Number o droo Character of soil to a depth of 3 feet: '- f Water table depth a SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal 4- 1 Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to'nearest: Well !Foundation Property Line SEEPAGE PITS Depth Size � __ ' Number r � r SUMPS-- �1 Distance to nearestF Well Foundation/1L� Property Line DISPOSAL PONDS ❑ I 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. e 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."Contractors hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for vvfh'ich this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." The-applicant must call for all d inspections. Complete drawing on're ers� sing. r � Signed Title. V/` �1/ Date: f� FOR PARTMIENT USE ONLY r l-� Area Application Accepted by Date it Grout Inspection by Date Final_lnsp"f 1ction by.11 r ate 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. Hazelton Av-e.;,f.0. Box 20Q9, Stk., CA 95201 ; FEE AMOUNT DUE AMOUNT REMITTED CK# RECEIVED BY DATE PERMIT'NO. INFO k CASH + EH 13-24(REV.1/86) EH 14-28