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r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ~ ' 1601 E. HAZEL i 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. aq� Job Address Ll— � _-- City Lot Size ' PM Owner's Name Address Phone { Contractor Address License No. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION❑ PUMP INSTALLATION ❑ 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 R ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic I Private ❑ Gravel Pack ❑ Tracy Type of CasingSpecifications \ n Public ❑ Other F1 Delta Depth of Grout Seal Type of Grout I I Irrigation —,.Approx. Depth t.l Eastern Surface Seal Installed by.... Repair Wark Done n Type of Pump " ~�Fi _ 'State Work Done_ 1 Well Destruction ❑ Well Diameter Sealing Material-(top 50'x, _ Depth. - Filler Material (Below 501. # t. TYPE OF SEPTIC WORK: NEW INSTALLATIONX REPAIR/ADDITION LI DESTRUCTION l I (No septic system permitted if public sewer isf ` ailable within 200 feet.) Installation will serve: Residence_ Commercial T Other } ! ;Number of living units: —I-- Number of bedrooms t 'Character of soil to a depth of 3 feet: Water table depth I SEPTIC TANK Type/Mfg 4206 42Q, Capacity No. Compartments PKG, TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well ff rr Foundation Property Line LEACHING LINE No. & Length of lines 3 To ' Total length/size ! • P FILTER BED ❑ Distance to nearest: Well Foundation Property Line t SEEPAGE PITS _Size .r Number-3 SUMPS Li Distance to nearest: Well Foundation Property Line I DISPOSAL PONDS ❑ 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 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." - A The applicant ust lisfar l re 'e inspections. Complete drawing on reverse side. Signed Xlif Title: Date: ��— E r. FOR DEPARTMENT USE ONLY Application Accepted by `V �1 �� Date t`2- a Pit or Grout Inspection by µ Date Final Inspection by ate Additional Comments: n S A?,& " ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104,,' El Tracy -835-63851- Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 Ilk FEE AMOUNT DUE AMOUNT REMITTED CKRECEIVEDRECEIVED BY DATE PERMIT'NO, INFO 0 / 4� - +.EH 13-24 M cv.1/85) I EH 14-29 CID 190