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APPLICATION FOR PERMIT�� SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA a 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. rux Job Address / City Lot Size u� PM Owner's Name Address �`T 2 Y Z 5 Phone 1-1 % v 5 3� -�� Phone Contract /r 'e s License No. TYPE OF WELL/PUMP: DISTANCE TO NEAREST: INTENDED USE ❑ Industrial ❑ Domestic/ Private F1 Public I I Irrigation Repair Work Done ❑ Well Destruction ❑ NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE _ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS TYPF OF WELL U Open Bottom ❑ Gravel Pack ❑ Other _..Approx. Depth Type of Pump Well Diameter Depth TYPE OF SEPTIC WORK: NEW INSTALLA PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Manteca Dia. of Well Excavation ❑ Tracy Type of Casing ❑ Delta Depth of Grout Seal l I Eastern Surface Seal Installed by H. P. State Work Done Dia. of Well Casing Specifications Type of Grout Sealing Material (top 501 Filler Material (Below 501 __ N I l REPA /ADDITION DESTRUCTION I 1 (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence 4".' Commercial _ Other Number of living units: l Number of Brooms Character of soil to a depth of 3 feet: Water table depth - Character SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines FILTER BED ❑ Distance to nearest: Well Foundation Total length/size_ Property Line SEEPAGE PITS I I Depth JAZ Size' X ZQ Number Z_ SUMPS Distance to nearest: Well Foundation �O / Property Line DISPOSAL PONDS ❑ r 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 Diltrict. 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." The applicant must call fo I req 'red inspections. Complete drawing on reverse side. Signed X Title: Date: l__ �^y 0 FOR DEPARTMENT USE ONLY 6 Appirition � Accepted by Date r Area or Grou It ction by l"9 atef - ` ¢ Final Inspection by ate? '"% Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 O Manteca 823-7104 O Tracy 835-6365 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 + EH 13.24 (REV. I/A 5. EH 14-28 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO CASH a