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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA 6 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 Disl6ct- Job Address [_ �L City ,� Lot Size PM Owner's Name Address z --,.— Phone ContractorN r� Address c License No. —V-6 —Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ... DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial n Open Bottom i=, Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private LI Gravel Pack Li Tracy Type of Casing Specifications \� Public L'1 Other F Delta Depth of Grout Seat Type of Grout 1 1 Irrigation Approx. Depth i 1 Eastern Surface Seal Installed by_ Repair Work Done Lj Type of Pump // _ H.P. —,T4--- —.— State Work Done ~ Well Destruction ❑ Well Diameter lG N Sealing Material (top 501 f __ Depth `+ � r Filler Material {Below 50') -- TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION I I DESTRUCTION I i (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial Other \ Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: __ Water table depth 9 SEPTIC TANK F1 Type/Mfg Capacity_,_._ No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size _- FILTER BED ❑ Distance to nearest: Well _ Foundation .� Property Line SEEPAGE PITS I l Depth --- Size — Number _ SUMPS LI Distance to nearest: Well Foundation Property line DISPOSAL PONDS i_I 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 folio ' : "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 Cali orni The applica call for all req u inspectio s. Complete drawing on rev rs side. Signed X Title: ('e&-- AIY\ 12 Date: 1`9EPARTMENT USE ONLY _7 Date AreaAPPlicatian Accepted by C/ Pit or Grout Inspection by D to Final Inspection by Date Additional Comments: D O K A ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 8.23-7104 ❑ Tracy 835-11385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 955201 1 FEE INFO Yom^AMOUNT DUE AMOUNT REMITTED CK 4 CASH RECEIVED BY DATE PERM17 N0. EH 13-24(REV,I%Hsi 1�7 EH 14-26