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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 01 (Complete in Triplicate) Application is heieby 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. Job Address 00 ty City Lot Size v PM Owner's Name Address PhonecZA.� Contractor , r Address 05 J License No.q%-3,5,y Ptlone9_ TYPE OF WELL/PUMP:0 NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION 171SYSTE REPAIR 17OTHER L1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINS DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTU ELL OTHER WELL PITS/SUMPS a� 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 TF1 — + I`1 Public ❑ Other ❑ Delta Depth of Grout SeafType of Grout I I Irrigation --.-Approx. Depth I I Eastern Surface Seal Installed by t V - : r Repair Work Done ❑ Type of Pump H.ft, _ — State Work Done'_ I t Well Destruction ❑Weil Diameter Sealin Material Stop 50'I Depth Filler Material (Below 50') ' -- TYPE OF SEPTIC WORK: NEW INSTALLATION i REPAIR/ADDITION l I DESTRUCTION l I (No septic system permitted if public sewer is available vwithin:200 feet) f Installation will serve: Residence` Commercial O�Ctheerr®, Number of living units°" Number+of bedrooms i r j Character of soil.tti a depth of 3 feet, = Water table depth SEPTIC TANK ❑ TypelMig Capacity - No. Compartments PKG. TREATMENT PLT. ❑ .+" � Method of Dispo k Distance to nearest: "W611 -"Foundation _ Pioperty Line + LEACHING LINE ❑ No. & Length of lines Total length/sizeY s k FILTER BED ❑ Distance to`nearest: 'Well L Foundation 1 Property Line L [. ' SEEPAGE PITS i I Depth 2_ Size Number' SUMPS Cl Distance to nearest: "'Well 4w�'" _Foundation ` Property Line DISPOSAL`PONDS ❑ r [ d 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 C rules and regulations of the San'Joaquin Local Health Di3trict. ' Home owner or licensed agent's signature certifies the following:`lcertify that in the performance of the work for which this permit ismissued;I:shall not.`7 employ-any person in such-manner as to become subject to workman's compensation laws of California." Contractors 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 appiican ust call fo ft-requir d inspections. Complete drawing on reverse side. Signed X Title: ° t _ Date: 4R DEPARTMENT USE ONLYy Application Accepted by _ ; Date�i r'�� Area PiY or Grout Inspection by ( DateA=A?_,( Final Inspection by Date r Additional Comments: _ ri I•r f n G - ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 95201EC �- I CK r INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. ...»,...,,,r �...'-..-lel J +.EH 13-241REV.I FH 5+ D,`� — VS EH 14-26