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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 r PERMIT EXPIRES TY,EAR 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, /r /.� Job Address ` '4- f� I Az9� City Lot Size PM 6 2' V Owner's (Vim�,lrf� �� /1 ddress f� � �" Phone Contractor.. Address License No. Phone /TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WECL PITS/SUMPS 4 � INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private, ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 11 Public C1 Other f=1 Delta Depth of Grout Seal Type_df Grout ` I I Irrigation �Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done k Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 f. TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION i Wo septic system permitted it public sewer is ai>ailable within 200 feet.) Installation will serve: Residence_.�. Commercial_ Other I • Number of living units: Number of bedrooms Character of soii to a depth of 3 feed f "'' Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT, ❑ Method of Disposal Distance to nearest: Well" "'" Foundation Property.Line Y. LEACHING LINE r ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size Number SUMPS Ll Distance to nearest: Wei " Foundation Property Line ' a,. 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 Di§trict.,. 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,1 shall employ persons subject to workman's compensa- tion laws of California. The applicant mu or all required inspections. Complete drawing on reverse side. �( Signed X ' _ Title: Date: 82_ S2 AP-4`1� FQR DEPARTMENT USE ONLY I. {I' Application Accepted by Date O Area f Pit or Grout Inspection by Date Final Inspection by pa Additional Comments: r ❑ Stk 466-6781 YLodi 369-3621 ❑Manteca 823.7184 El 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 DUE AMOUNT REMITTED CASH RECEIVED BY pATE PERMIT'NO. +.EH 13-24(REV.I/e 5) EH 14-28