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- APPLICATION FOR PERMIT 1 SAN JOAQUIN LOCAL HEALTH DISTRICT ' 1601 E. HAZEL T ON AVE., STOCKTON, CA " Telephone.(209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUE (Complete in Triplicate) -�►� Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install rhe eiWPscA10�d.'T a Iication is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules an egu a ions of the San Joaquin Local Health District. Job Address ,19 City L/7T 1 1C e_ LotSize PM Owner's Name Address Phone ,q I �N�V Contractor• Ad�r �ne� � � — TYPE 0 /PUMP: NEW ELL Eln�- WELL REPLACEMENT ElDESTRUCTION ❑ PU P INSTALLATION ❑ SYSTEM REPAIR,_El _ ._. . OTHER ❑ DISTANCE TO NEAREST: SEPTIC-TANK SEWER'LiNES^ `DISPOSAL FLD. PROP. LINE FOUNDATION. AGRICULTURE WELL OTHER WELL PITS/SUMPS i INTENDED USE s TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS T E-1Industrial ❑ Open Bottom 11Manteca Dia. of Well Excavation Dia. of Well Casing i ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy- - Type of Casing Specifications f"1 Public Cl Other Cl Delta Depth of Grout Seal Type of Grout _. 11 Irrigation Approx. Depth •d 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: N l 1 REPAIR/ADDITION l 1 DESTRUCTION o septic system permitted if public sewer is _ vailable within 200 feet.) i Installation will serve: -ResidenceCommercial'_ Other " Number of living units: Number of bedrooms t Character of soil to a depth sof 3 feet: Water"table depth SEPTIC TANK lei' Type/Mfg Capacity '"""'"-"No:Compartments PKG. TREATMENT PLT. ❑ ( w _ '' Method of Disposal Distance to nearest: Well Foundation Property.Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 1 1 Depth Size` Number SUMPS Ll Distance.to nearest: Well ' Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that thework.will be done in accordance with San Joaquin county ordinances, statelaws, 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 applicant m st call for all required inspections. Complete drawing,on reverse side. Signed X Tit Data 1. FOR DEPAR MENT.USE ONLY _ K Date Area Application Accepted by Pit or Grout Inspect n Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 U Manteca 823-7104 0 Tracy 83 - IWA Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT•NO. INFO +.EH 13-24(REV.a/n5) EH 14-2e '' � -