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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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. JobAddress © s / City Lot Size PM Owner's Name � '�/' Address Phone, v �� Carttractor;CCL ` 0!Address/Z A/ 10 r1 License No7 �� Phone TYPE OF WELL/PUMP: NEW W LL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGR( ULTURE ELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AR NSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f Public Cl Other fl Q_Ito Depth of Grout Seal Type of Grout I i Irrigation _Approx. Depth 1 I Eastern Surface Seal installed by _ 1 Repair Work Done ❑' Type of Pump .P. =- State Work Done_ Q Well Destruction : l] Well Diameter ealing aterial (top 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION r REPAIR/ADDITION I 1 DESTRUCTION V (No septic system permitted if p lic sewer is �r�ilable withi 200 f� Installation will serve: Residence commercial Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: ON Water table depth SEPTIC TANK t ElType/Mfg Capacity _ No. Compartments PKG. TREATMENT PLT. ❑ A Method of Dispo I Distance to nearest: Well JDA_+Foundation Property Line LEACHING LINE C1 No. & Length of lines Total length/size FILTER BED ""❑"Distance to nearest: Well O Foundation 7— Property Line SEEPAGE PITS I I Depth Size _ Number SUMPS L1 Distance to nearest: Well Foundation /r�u Property Line DISPOSAL PONDS ❑ 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 t 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 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 ust call for equired i pections. Complete drawing on reverse side. �{ Signed X Title: Date: Lam/ V s FO DEPARTMENT USE ONLY J Application Accepted by _ Date < Area Pit or Grout Inspection by ate Final Inspection by 4 Date I, /- Additional Comments: ^ r� -S Q_ ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 923-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bo'x 2009, Stk., CA 95201 INFO FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE p pPEERMIT'NOO, +.EH13-241REV.1/65) EH t4-26