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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.HAZELiON AVE., STOCKTON, CA i Telephone (209) 466-6781 o PERMIT EXPIRES YYEAR 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. t City ��C' Lot Size PM Job Address 41 hr°Ttd2g Phone Owner's Name '�� — Address. . ^^'- ILC r Address_ VIP j License No.r��so1 Phone Contractor _. TYPE-CIF WELL/PUMP: ter._._ NEW,WELL ❑ _ WELL REPLACEMENT ❑ DESTRUCTION ❑ - PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ r 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 pia. of Well Casing Ll Industrial 0 Open Bottom LJ Manteca Dia- of Well Excavation e of Casing Specifications , 0 Domestic/Private ❑ Grave! Pack LJ Tracy TYp g Type of Grout [l Public 171 other C1 Delta Depth of Grout Sea! 1 l Irrigation _-.Approx. Depth 11 Eastern Surface Seal Installed by Repair Work,Done 11 Type of Pump H.P. State Work Done' Well Destruction 0 Well Diameter Sealing Material (top 50'1 Depth Filler Material (Below 501 (Nosystem TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION f I DESTRUCTION I I availabllerwithin 200 feetr.]ed if public sewer is Installation will serve: Residence Commercial— Other t" Number of living units: Number of bedrooms Water table depth Character of soil to a depth of 3 feet: SEPTIC TANK 1 �TYpe/Mfg L r CT4 ', Capacity�i�Q�_ No• Compartments • _; r Method of Disposal PKG. TREATMENT PLT. 0 1 Distance to nearest: Well 1�D� Foundation Q_Q_�,_-_ Property Line_.. —.._ LEACHING LINE &_Length of lines Total length/size FILTER BED' r ❑ Distance to nearest: Well Foundation Property Li6e Number v !� Y — {SEEPAGE PITS l�i Depth ��... -Size A-- —r 1 SUMPS Distance to nearest: Well .Foundation Property Line DISPOSAL PONDS ❑ - 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: 111 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 must call pfor all req iredd inspections, Complete drawing on reverse side._ ` Q r X ! I Title: Date: Signed X �k F DEPARTMENT USE ONLY 01 Area Application Accepted by °' ®�'� Date Final Inspection by A ""Date Pit or Grout Inspection by DataAOr `' t I Additional Comments: k ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 836-6386 r Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95203 CK FEE AMOUNT DUE AMOUNT REMITTED RECt IVED B � Y DATE PERMIT NO. INFO 1� CASH _ t EH 13-24(R EV.I/X51 / EH 14-2a -