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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ' 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 'I 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 4 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 I Local Health District. 1 9s Ci Lot Size PM Job Address Wensen,, A "tiTI.Phone Owner's Name iContractor's Name No. Phone TYPE OF WELL/PUMP: NEW WELL 1-1WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ f 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 ❑ Gravel 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 Well Destruction ❑ Wall Diameter Sealing Material !top 501 3 Depth- Filler Material (Below 50'1 TYPE OF SEPTIC WORK;. NEW,INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ MO septic system permitted if public sewer is a f �"�, l available within 200 feet.) Installation will server Residence Commercial Other r Number of living units:_ Number-of bedrooms'• Character of soil to a depth of 3 feet: Y Water table depth. SEPTIC TANK C1Type/Mfg L i Capacity ' No. Compartments PKG. TREATMENT PLT. ❑ ! Method of Disposal Distance to nearest: Well i Foundation Property Line. EI LEACHING LINE X No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Tht Foundation_ Property Line 3 i \ } -,: °Size f' _ - Number Det SEEPAGE PITS Depth ' ; c tze j r } SUMPS Distance to nearest- Well ri) _ Foundation 7�. Property Line— DISPOSAL PONDS ❑ fi, 4 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.f �� 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 Califomia."Contractor's hiring or sub-contracting signature x 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- tlon-Ia`ws of California," The appections..Comyete drawing n rse'side f Signed Title: Date: D ! FOR DEPARTMENT USE ONLY Application Accepted by r Date / D �I k Date Final Inspection by !C Date` i Pit or Grout Inspection by Additional Comments: ❑ Stk .466-Ml ❑ 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 iCK FEET DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. INFO Q/ + EH 13-241REV.10/83) O 4 / I '� EH 14-26 k