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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 JCornplete 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 Dist13_5( f ,(, (y Job Address �� ` Citys�o` O Lot Size Owner's Name Addre s _SPhone 3Z—,_:F .,;� 7 Contractor- Address License No. Phone I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ,p PUMP INSTALLATION L7 SYSTEM REPAIR ❑ OTHER i i DISTANCE TO,NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD./va,r PROP.-LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ZO-01 U INTENDED USE -TYPE OF WELL PROBLEM AREA—CONSTRUCTION SPECIFICATIONS t ❑ Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing: ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications _ (`l Public ❑ Other H Delta Depth of Grout Seal Type of Grout r I i Irrigation _.-Approx. Depth I I Eastern Surface Seal Installed by P � Repair Work Done ❑ Type of Pump H.P. State Work Done_ t ir Well Destruction .. ❑ Well Diameter Sealing Material (top 50'1 - t .,Depth Filler Material (Below 50') :TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION\LI. DESTRUCTION') I INo septic system permitted if public sewer is' available within 200 feet.) 1 Installation will serve Residence_ Commercial— Others Number of living units: Number of bedrooms r _ Character of soil to a depth of 3 feet: -t Water table depth -•—SEPTIC TANK ❑ Type/Mfg "fC p city No. Compartments 4 PKG. TREATMENT PLT. ❑ —" Method of Disposal Distance to nearest: Well Foundation - Property Line i LEACHING LINE ❑ No. & Length of lines Total length/size _i FILTER BED ❑ Distance to nearest: Well Foundation Property Line_ � r l SEEPAGE PITS ( I Depth Size Number. l ` SUMPS L1 Distance to nearest: Well Fdundation Property Line I DISPOSAL PONDS ❑ hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county-brdinances, 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 compo sn a ion-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." I The applicant mus all for all required inspections. Complete drawing on reversseeide.'r,� /ms`s_,_ , Signed X Title: Date: FOR DEPARTMENT USE ONLY G Application Accepted by O //_ r Date�/�� 47 Area f Pit or Grout Inspection by Date 7 Final Inspection by - ,— Date LL -7 Additional Comments: / ` �a !�� I ❑ Stk 466-6781 ❑ 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 61 i FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO �e�((��VCASH +.EH13-241REV.t/H51 �+�0 �,V �� EH 14-28 � 3