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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON-AVE., STOCKTON, CA f 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 Rules and Regulations of the San Joaquin Local Health District. Job Address / � Ci� Lot Size PM Owner's Name ess � C! r� Phone Contractor Address �� License No. Phone ' TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ £ 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 CJ Gravel Pack ❑ Tracy Type of Casing Specifications 71 Public Cl Other Cl Delta Depth of Grout Seal Type of Grout _ ! I Irrigation __.Approx. Depth l 1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H,P. State Work Done _ v Well Destruction ❑ Well Diameter Sealing Material Itop 50') Depth Filler Material (Below 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION l I DESTRUCTION lNo septic system permitted it public sewer is C 1 vailable within 200 feet.) kQ 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 Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line 1, LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS { I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line ` DISPOSAL PONDS ❑ CA 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 i�thhe rformance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The apphca t c II for all re rre tions. Complete drawing on re rse side. �/ } signed X Title: Date: ll 3 FOR DEP RTMENT USE ONLY / Application Accepted by Date Area j Pit or Grout Inspection by Date Final Inspection b Date Additional Comments: 210 / ❑ Stk 466-6781 ❑ Lod 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 FEE A INFO AMOUNT DUE AMOUNT REMITTED C 3H RECEIVED BY DATE PERMIT'NO. +.EH14-24-26(REV.t/r<51 `Q 3, 17V7 X7 96 ; r