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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE 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 Local Health District. t Job Address City_A >� Lot Size �� � PM Owner's Name Address 'sT �—1 Phone Contractorh 1, "we Address License No. Phone 'TY PE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER IV 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 \ ❑ Industrial ❑ Open Bottofn ❑ Manteca Dia. of Well Excavation Dia. of Well Casing VDomestic/Private ❑ Grad Pack ❑ Tracy Type of Casing .01 .� r 1-1 Public Specifications f_1 Other n Delta Depth of Grout Seal I I Irri ation ` - —Type r E ofGrout t1 —_Approx. Depth I 1 Eastern Surface Seal Installed by)' — Repair Work Done E Type of Pump H.P. State Work pone Well Destruction Cl Well Oiameter Sealing Material (top 50') Depth Filler Material (Below 50'1 ,TYPE OF SEPTIC WORK: NEW INSTALLATION !1 REPAIR/ADDITION ! I DESTRUCTION ! (No septic system permitted if public sewer is y available within 200 feet.) Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: 17 Water table depth SEPTIC TANK ❑ Type_ /Mfg Capacity—� PKG. TREATMENT PLT. El / L� ` No. Compartments Method of Disposal { Distance to nearest: W41 Foundation Property Line LEACHING LINE Q No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well JFoundation Property Line f SEEPAGE PITS I 1 Depth Size Number Jand SUMPS L] Distance to nearest: Well Foundation DISPOSAL PONDS ❑ Property Line I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state l 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 call r qu' d in cY ns. Complete drawing on revs-a side, v Date: Signed Title: 4 ,Gnc�G�] � /t FOR DEPARTMENT USE ONLY Application Accepted by Area f Pit or Grout Inspecti y��- Date Final Inspection by Date Additional Comments: k 0 ❑ Stk 466-6781 ❑ Lodi 369-3621 0 Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DU AMOUNT REMITTED RECElVEp BY /n� CASH DATE PERMIT'NO. a EH 13-24(AEV.r/n51 �4 OV EH 10.2e �1 ' l / .