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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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. rr �/q,.►y. L {p lD l l V -fir City (K �f� Vl of Size. JL0 ��I"�J PM Job Address f r Owner's Name IF'�fll rC► #Q ess _ S� [,W U'e— M A Lq-r—C lone 2 .3 a Contractor Address License No. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 1:1 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL . PITS/SUMPS Ik INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS LJIndustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Ll Domestic/Private 1-1Gravel Pack ElTracy Type of Casing Specifications I 1'1 Public Cl Other ' it Delta Depth of Grout Seal Type of Grout i I Irrigation Approx. Depth I i Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 s Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION I I DESTRUCTION I. I availablelwthin 200 feet.)system if public sewer,is Installation will serve: Residence Commercial_ Other Number of living units: —I Number of bedrooms'1 r - Character of soil to a depth of 3 feet: 5 A--m- L-Q Water table depth r SEPTIC TANK Type/Mfg Pd �-' -on C 1rC7-E Capacity_( 6 No. Compartments PKG. TREATMENT PLT. © Method of Dispral t iDistance to nearest: Well p0� "Foundation 1 2. Property.Linep7" I LEACHING LINE A-'No. & Length of lines �- r` r Total length/size / (40 Z FILTER BED ❑ Distance to nearest: Well P 400- 'i" Foundation Property Line �O SEEPAGE PITS i I Depth Size Number SUMPS ❑ Distance to nearest: Well 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 rulesandregulations 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, l 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,l shall employ persons subject to workman's compensa F lion laws of Californi S The app"ca must a for all required inspections. Complete drawing o verse side. Signed Title: Date: [! v UX F DEP TMENT USE ONLY Application A epled by Daterea � Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: E Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 0 Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 20W, Stk., CA 95201 FEEAMOUNT DUE AMOUNT REMITTEDCASH RECEIVED BY DATE PERMIT'NO. INFO ♦.EH 1324(REV.1/A W <>�� 'n EH 14-26