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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT L� 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 Ryles and Regulations of the San Joaquin Local Health District. / Ci Job Address 'v�k of Size PM Phone Owner's Name fC/' / �^ Address 'C iN Address A &OX S�� 2_3License No. Phone Contractor p vd� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 11DESTRUCTION ❑ 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 Dia. of Well Casing ❑ Industrial ❑ Open Bottom. ❑ Manteca Dia. of Well Excavation Type of Casing Specifications E3 Domestic/Private ❑ Gravel Pack El Tracy yp g T e of Grout El Public ❑ Other ❑ Delta Depth of Grout Seal Type ❑ Irrigation ---Approx. Depth El Eastern Surface Seal Installed by S 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 ❑ REPAIR/ADDITION El DESTRUCTION ❑ (No septclable htem rented if public sewer isavay� Installation will serve: Residence-G Commercial_ Other 0 Number of living units: Number of bedrooms Water table depth OO Character of soil to a depth of 3 feet: ba g Z Capacity No. Compartments SEPTIC TANK El Type/Mfg Method of Disposal PKG. TREATMENT PLT. ❑ Distance to nearest: Well Foundation Property Line LEACHING LINE 11 No. length/size No. & Length of lines '� Property Line FILTER BED El Distance to nearest: Well Foundation ' r � Cv � SEEPAGE PITS 2'-- Depth Size Number f SUMPS ❑ Distance to nearest: Well Foundation lO Property Line !U 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 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 signature shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hirior ng to workman's sub-contracting certifies the following:"I certify that in the performance of the work for which this permit is issued,I shall employ pe 1 tion laws of California." The applicant mu c for require inspections. Complete drawing on re/ve�rse side. �� S Signed _ Title: Date: FOR DEPARTMENT USE ONLY � Date Area Application Accepted by —= g j :I a 3 Pit or Grout Inspection by �- Date _ Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 rmit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 Applicant- Return all copies to: Environmental Health Pe FEE CK# RECEIVED BY DATE PERMIT"NO. INFOZn AMOUNT REMITTED CASH EH 13-24(REV•1/85) EH 14-28