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APPLICATION FOR PERMIT ' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON ON AVE., STOCKTON, CAS Telepho'he (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 Rules and Regulations of the San Joaquin Local Health District. I 167 Cit Lot Size PM 1 Job Address r a Owner' am Address ? Phone } / ✓ Contrac Addre^ Cm � License a Phon � ~ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER D DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PR FOUNDATION AGRICULTURE WELL OTHE PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUC PECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Di ell Excavation Dia. of Well Casing ` Specifications ❑ Domestic/Private 171 Gravel Pack E1 Tracy Type of Casing M Public Ll Other a Depth of Grout Seal Type of Grout - I 1 Irrigation —.Approx. D "I 1 Eastern Surface Seal installed by - 1\ Repair Work Done ❑ Type mp H•P. State Work Done k Well Destruction ell Diameter Sealing Material (top 501 -" -- Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I-1 REPAIRIADDITION I 1 DESTRUCTIONINo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial _ Other Number of living units: Number of bedrooms �« Water tabic depth Character of soil to a depth of 3 feet: p I SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments A PKG. TREATMENT PLT. ❑ , { Method of Disposal rn 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 11 Depth Size _ Number i SUMPS L] Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 Di§trict." 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 for all re uired inspections. Complete drawing on�See.Sign Title: -'`'' Date: "FOR DEPARTMENT USE ONLY 13 Application Accepted by Date 4 Pit or Grout Inspection by Date Final Inspection by Date - ffffi Additional Comments: ID Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823 7104 El Tracy 835 6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO Q -/y +"EH 13-24 4REV.1 i K 51 EH 14-29