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APPLICATION FOR PERMIT r> SAN JOAQUIN LOCAL HEALTH DISTRICT I I w a 1601 E. HAZE i ON AVE-., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made toithe 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 He ions of the San Joaquin Local Health District. r job Address / � �" City � Lot Size PM .l Phone Owner's Name Contractor Address License No. Phone -510 TYPE OF WELL/PUMP: I� NEW WELL ❑ WELL REPLACEMENT DESTRUCTION EI! PUMP INSTALLATION El 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 El Industrial ❑,Open Bottom 11Manteca Dia. of Well Excavation Dia. of Well Casing I ❑ Domestic I Private ❑ Gravel Pack _❑ Tracy Type of Casing Specifications TYp I �r e of Grout F] Public Other w [-1 Delta Depth of Grout Seal I i Irrigation -Approx. Depth. I I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. x. State Work Done Well Destruction CJ Well Diameter Seating Material (top 50' Depth ' F ,_ Filler_Matetial (Bel 1 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION fL DESTRUCTION l I INo septic system permitted if public sewer is iI 4 0% t available within 200 feet.) Installation will serve: Rel idence— Commercial Othetk " Number of living units: j� Number of bedrooms ,3 j Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK E. Type/Mfg } Capacity 1 a No. Compartments PKG. TREATMENT I I-T. 13Method of Disposal Distance to nearest: Well t Foundation �* Property Line O LEACHING LINE :❑11No. & Length of lines Total length/size FILTER BED I Distance to nearest: Well. Foundation !V,47 .... Property Line SEEPAGE PITS l Depth —Size Number f SUMPS ❑i Distance to nearest: - We Foundation ��a ti Properly Line _ .— DISPOSAL PONDS ❑i t 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 thelSan 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 shalt 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 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." I The applicant must call for al ired inspectio s. Complete drawing on reverse side. "Imo" Signed Title: �f�4_a ` Date: ` FOR DEPARTMENT USE ONLY Application Accepted by Date Area i Pit or Grout Inspection by Date Final Inspection by Date f Additional Comments: I d Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant,- Return all copies to: Environmental Health Permit/Services 1601.E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY 'DATE PERMIT"NO. INFO CCASH�y �� + EH 4IREV.iins1 EH 14-2