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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA f s Telephone (209) 466-6781 PERMIT EXPIRES 1-YEAR FROM DATE ISSUED f {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. _ C/I Job Address '" ' PM' Cit Lot Size 1_4 Add_less Phone L _.. L Owner's Name Contractor r ��,. Address r� License No. // Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLAGEMENT El DESTRUCTION ❑ PUMP INSTALLATION r SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK — SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELLt� PITS/SUMPS INTENDED USE TYP WELL PROBLEM AREA CONSTRUCTION SPECIFIC 0 ❑l I/n� trial pen Bottom ❑ Manteca Ria. of Well I cavati n Dia. of Well Casin Domestic/Private Gravel Pack ❑ Tracy Type of Casing Specifications, f'1 Public p❑ Other ❑ Delta Depth of Grout Seal T e of Grout I 1 Irrigation �$O .Approx. Dept Eastern Su Seal Installed by - Repair Work Done L3 le le,of Pump N.P. State Work Done Well Destruction ❑ Vell tam tem Sealing Materi I Itop 50'1 mer uto/{ �� hg Depth Filler Material IBelow 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REP AIR/ADDITION I I DESTRUCTION I l Mo septic system permitted if public sewer is # available within 200 feet.i 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 l PKG. TREATMENT PLT. ❑ Method of Disposal r Distance to nearest: Well Foundation Property.Line LEACHING LINE Ll No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth 3 Size Number 1 SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ i 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, l' employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature I 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." ` k $ The applican t c or r o s. Complete drawing on rev a side. ad in cti Signed X Title: __ Ql -- Date: FOR DEPARTMENT USE ONLY Application Accepted by 4Date Date Area Pit or rout Inspection by 6 �" Final inspection by Date Additional Comments: t ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 Q Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 k FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE =IT'NO. INFO a +.EH 13-241REV.1/85Y EH 14-26 v VVV