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APPLICATION FOR PERMIT ) SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA 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 rJobAddress h District. } ,/� �� /(1 h 4 CityLot Size plyme �!b 5 �/ U� Address /6-/�p /f, � Phone �Sr 1Address 5�'�'�?E.� License No. Phone TYPE OF WELL/PUMP; NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ ER ElDISTANCE TO NEAREST: SEPTIC TANK SEWER LI DISPOSAL F PROP. LINE FOUNDATION AGRICULTUR ELL OTHER LL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CON RUCTION SPE CATIONS ❑ Industrial Cy Open Bottom ❑ Manteca Dia. of 11 Exc ion Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of C ' g Specifications n Public I7 Other ❑ Delta Dep f Gro t Seal I I Irrigation A Type of Grout q —.-Approx. Depth ( I Eastern unlace Seal In ailed by Repair Work Done ❑ Type of Pump a H State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I ] DESTRUCTION (No septic system permitted if public sewer is Installation will serve: Residence_ Commercial vailable within 200 feet.) _ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: ! i Water table depth SEPTIC TANK Type/Mfg Ca acit p Y No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: ; Well Foundation Property Line LEACHING LINE . ❑ No. & Length of lines Total length/size ... VVV FILTER SED ❑ Distance to nearest: Well Foundation " � Property Line , SEEPAGE PITS I I Depth Size Number I SUMPS Ll Distance to nearest: Weil '1 Property Line DISPOSAL PONDS - Li Foundation- i 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, rules and regulations of the San.Joaquin Local Health District. state laws, and Home owner or licensed agent's'signature.certifies the following: R to an "1 certify that in the performance of the work for which this permit is issued, I shall not emI p y y person in such manner as to become subject to workman's compensation laws of California." Contractors 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." /The applican ust.call for all required inspections. Complete-drawing on reverse side.. ]�5igned Title: 'f a�GIJT��/ /ff """ Date: FOR DEPARTMENT USE ONLY Application Accepted b Date _ 1^ Area Pit or Grout inspection Date Final Inspection by � Date Additional Comments: ElSik 466-6781 L1Lodi 369-3621 k, ❑ Manteca 7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmenta�-Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED INFO CK RECEIVED BY DATE PERMIT'NO. + EH 13-24(REV.t i K sl EH 14-26