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FOR PERMIT APPLICATION SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CASys, PERMIT Telephone (209) 466-6781 I�/� 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. . Job Address L� Alf. C&I—I `-+AA#✓City Lot Size 1/a' PM Owner's Name— Address Phone Contractor'FA Address/V� �� Lic se No. Pho 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 Ll Other ❑ Delta Depth of Grout Seal Type of Grout _. I I Irrigation --Approx. Depth 11 Eastern Surface Seal Installed by _ "U 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 LI DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serv( i ence X Commercial they Number of living unit Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Type/Mfg. Capacity o. Compartments I PKG. TREATMENT PLT. ❑ Method of Disposal 077 Distance to nearest: Well _ Foundation L-;;V— Property.Line LEACHING LINE No. & Length of lines Total length/size { FILTER BED ❑; Distance to nearest: Well 7116 Foundation Property Line SEEPAGE PITS Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line j DISPOSAL PONDS Ll 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 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 requirins ctions.`Complete drawing on reverse side. Signed Title: Date: FO DEPARTMENT USE ONLY Application Acceptedby n"�� --- Date S_ _c�0_Area Pit or Grout Inspection by ,Date Final Inspection by 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 95201FEE �. INFO OUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. t� +.EH 3-24(REV.tixS) 0°� 1� �. 32 . Q' Ub EH 14-2e - ... iff { _. i