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" k APPLICATION FOR PERMIT Y � SAN JOAQUIN LOCAL HEALTH DISTRICT " 1601 E. HAZELTON AVE., STOCKTON, CA `2/19 Telephone (209) 466-6781 L,A (� PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) Application is eleby 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 compli ce 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 bis ict. t Job Address v I City Lot Size PM j Owner's Name N Address !/" i " Phone j Contractor `f Address' License No. Phone 1 TYPE OF WELL/PU P: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS O }� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack, ❑ Tracy Type of Casing Specifications 171 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation --Approxi Depth I 1 Eastern- Surface Seal Installed by 1 Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material.(top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I'l REPAIR/ADDITION l 1 DESTRUCTION/4 INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_, Commercial— Other Number of living units: Number of bedrooms 7 Character of soil to a depth of 3 feet: Water table depth li SEPTIC TANK ❑ Type/Mfg 1 N Capacity No,Compartments 1 PKG. TREATMENT PLT. ❑ Method of Disposal I Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length size FILTER BED ❑ Distance to nearest: Well Foundation Property Line . . P SEEPAGE PITS I'] Depth Size ---Number F , SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepaied 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 DFstrict. , 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 Work ma n's-comperisation 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 f fl required ' pections. Complete drawing on reverse side. Signed X Title: C/ f/1E� �— Date: FOR DEPARTMENT USE ONLY s Application Accepted byy ,� Date Area f Pit or Grout InspectionLb , Date spection� DateAdditional Comments: { K r � ❑ Stk 466-6781 11 Lodi 369-3621 ❑ Manteca 823-7104. ❑ Tracy 635-6385 Applicant - Return all copies to. Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT-NO. INFO SH -�� +.EH 13.241REV.r/n5) EH 14-2a U s