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Zi l 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) 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. s" L_. a_ 1 1, #, r Job Address City trot Size PM Owner's Name >I-, Address t� f � � i� .ti x., , a ��a � '046ne Contractor Address License No. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ 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 M Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation __Approx. Depth ( 1 Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l 1 ESTRUCTION l 1 (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence commercial_ Other L_� f Number of living units: Number of bedrooms T x Character of soil to a depihxof•3 feet: + t;� .' Water table depth SEPTIC TANK ❑.Type/Mfg f' : k, � (_ Capacity p 0 U No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation f / Property Line („26) LEACHING LINE lNo. & Length of lines 64 : Total length/size iJ FILTER BED ❑ Distance to nearest: Well — Foundation �:f •> Property Line^� /�f SEEPAGE PITS Depth •" A Size Number SUMPS Ll Distance to nearest: Well 1 061 Foundation Property Line .. DISPOSAL PONDS ❑ 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 Di§trict. 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,I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. q„ Signed X Title: Date: w _ FOR DEPARTMENT USE ONLY f Application Accepted by `' Date .L.-a, Area Pit or Grout Inspection by Date Finel Inspection by _77,< Date 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 AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'NO. +.EH 13-24(REV.1/"5) EH 14-28