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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) uin Local Health District for a permit to construct and/or install the work herein described.This application is Application is hereby made to the San Joaqth made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules an j Regulns� ofe San Joaquin Local Health District. "f 3 wC/' A�ov�+, City Lot Size PM Job Address 201 Z�(� Address Owner's Name Phone Phone Contractor's Name �� License No;�- r j TYPE OF WELL/PUMP: NEW WELL ❑ }SWELL REPLACEMENT E3DESTRUCTION 1-1 PUMP INSTALLATION`❑ SYSTEM REPAIR ❑ OTHER ❑ DISPOSAL FLD. DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES k PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well-Excavation ❑ Domestic/Private ❑ Gravel Pack ❑ TIracy E Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Public -� ❑ Irrigation ---Approx. Depth ❑ Eastern - Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction' E3 Well Diameter Sealing Material (top 50'1 Ii Depth a Filler Material(Below 501)` 1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIO (No septic systthinem permitted if public sewer is Installation will serve: Residence Commercial; Other Number of living units: Number of bedrooms ; Character of soil to a depth of 3 feet: ! f Water table depth SEPTIC TANK ❑ Type/Mfg �� Capacity No. Compartments PKG. TREATMENT PLT. ❑ r � , - Method of Disposal Distance to nearest: Well 'Foundation A Property Line LEACHING LINE ElNo. & Length of/tries " Total length/size I ! Foundation PeftY FILTER BED - ❑ Distance to nearest: Well,� � J Pra tine SEEPAGE PITS ❑ Depth Size Number ' SUMPS C1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ElE' that the work will be done in accordance with San Joaquin county ordinances, state laws, and I hereby certify that I have prepared this application 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, 1 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 m r all requir inspections. Complete drawing on reverse side. ,+ SignedII Title: ele! � � a Date: I FOR DEPARTMENT USE ONLY l pate46 a V Application Accepted by Pit or Grout Inspection by. Date Final Inspection by Additional Comments: [1 Stk 466-6781 ..El Lodi 369-3621 C1 Manteca 823-7104 ❑ Tracy 835 fi385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO AMOUNT DUE A UNT REMITTED CASH RECEIVED BY SATE ppRMIT`'NO. +EH 1324 IREV.10!83} EH 1426