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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HE LTH DISTRICT 1601 E. HAZELTON AVE., TOCKTON, CA - Telephone (209) -6781 L PERMIT EXPIRES1 YEAR FROM DATE ISSUED .t (Complete in Triplicate) r 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. - /� f' Job Address 2 '"' City Lot Size PM r Owner's Name Address 7 "`'1/. C� �l Phone Contractor Address A License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION "❑ w PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK M1 SEWER LINES DISPOSAL FLD, PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS t INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPE (CATIONS m ❑ 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 Sea .- Type of Grout ❑ Irrigation �4pprox. Depth ❑ Eastern Surface Sea_I Instal d by' I Repair Work Done ❑ Type of Pump H.P. w`State ork Done Well Destruction ❑ " Well Diameter Sealing Material (top 501 Depth Filter Material (Below 501 " r TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is vailable within 200 feet.) Installation will serve: Residence Commercial Other _ Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: -^-- —• Water table depth SEPTIC TANK ❑ Type/Mfg F Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal t Distance to nearest: Well- -Foundation Property Line LEACHING LINE n No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line k SEEPAGE PITS ❑" Depth Size Number SUMPS . . ❑ Distance to nearest: Well Foundation Property Line r DISPOSAL PONDS ❑ y 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. 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 f all r uired ins ctioris. Complete drawing on r verse sid I �: Signed X a Title: ra� �w��-r Date: e� FOR DEPARTMENT USE ONLY Application Ac ted by. Z Date / D V Ara Pit or Grout Inspectio by Date Final inspection by Date Additional CommentsAV ❑ Stk 466-6781 Lodi 369 3621 - ❑ Manteca 623-7104 ❑ Tracy 8355-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE 4 INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY' DATE PERMIT"NO. i + EH 13-241AEV.i/A5) EH 1428 �/ j