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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T 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. -726 Job Address v cle City L t Size ' PM Owner's Name Address Phone Z, Contractor o Address License No - a —Phone TYPE OF WELL/PUMP: NEW WELL ❑ ELL REPLACEMENT El DESTRUCTION El PUMP INSTALLATION ❑ SY:::�L _ REP El OTHER El DISTANCE TO NEAREST: SEPTIC TANK SEWER L NES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICUL URE OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA ONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ('1 Public Cl Other Ll De Depth of Grout Seal Type of Grout I I Irrigation __Approx. Depth I I astern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50'► Depth Filler Material (Below 50'► —_ TYPE OF SEPTIC WORK: NEW INSTALLATION l REPAIR/ DDITI I I DESTRUCTION I I (No septic system permitted if public sewer is v „ /avail ,�/� e wit hin %fe 4 Installation will serve: Residence_ Commercial_ er Wl� Number of living units: Number of bedrooms _ .� ` Character of soil to a depth of 3 feet: y20Q0 Water table depth SEPTIC TANK ❑ Type/Mfg t i 12043 No. Compartments PKG. TREATMENT PLT. ❑ Method of Dis sal Distance to nearest: Well Foundation&L Property Line To LEACHING LINE ❑ No. & Length of lines Total length/size _ FILTER BED El Distance to nearest: ell Foundation;�� Property Line )/ SEEPAGE PITS 11 Depth _Size eNumber SUMPS Ll Distance to nearest: Wll oundation Property Line DISPOSAL PONDS El ` Is-61�0 1 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." The applicantAust call for quired in pections. Complete drawing on reverse side. c �� Signed X Title: / /l1_ Date: ARTMENT USE ONLY \ r Application Accepted by Date Area Pit or Grout Inspection by Date/yJ "� A Final Inspection by Datpl� G Additional Comments: ❑ 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 95201 FEE INFO A UNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT NO. + EH1EH 14-263.24(REV.i/85) r V-0 /11 ' �� '�