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APPLICATION FOR PERMIT 'I SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA �}t Telephone (209) 466-6781 y` 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. Co j c �� L�/ Lot Size /1�x �' PM Job Address _ City. �� Address Phone Owner's Name � - -- " !?hone Contractor =' Address 4' C License No. TYPE OF WELL/PUMP:' NEW WELL FJ WELL REPLACEMENT ❑ DESTRUCTION LJ PUMP INSTALLATION LlSYSTEM REPAIR Q OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE f FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS f` IN USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I v ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Industrial 4Specifications ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type bf Casing`' ❑ Public F7 Other Cl Delta Depth of Grout Seal Type of Grout — 1 j I 1 Irrigation _Approx. Depth l I Eastern ;Surface Seal Installed by t 1 Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Stop 501 Depth Filler Material'{Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I 1 (No septic system permitted if public sewer is available within 200 feet.) 4 i Installation will serve: Residence- - Commercial— Other -a Number of living units: — Number of bedrooms_. iWater table depth Character of sail to a depth of 3 fee#: � � - SEPTIC TANK ❑` Type/Mfg _ �+ • Cap _". acity -.- No. Compartments Tom,: r PKG. TREATMENT PLT. L1 �$ i f Method of Disposal ; Distance to nearest: Well Foundations Property Line LEACHING LINE p No. & Length of lines Total length/size FILTER BED [❑ Distance to nearest: Well f 41',Q ion a�Fo undat3;S' Pt Property Line FT a rf. 1 i SEEPAGE PITS l I Depth � Size Number _ � _ — SUMPS Cl Distance to nearest: Wei �Foundafion Property Line tk DISPOSAL PONDS ❑ I p 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 i rules and regulations of the San Joaquin Local Health District. " �„ t Home owner or licensed agent's signature certifies the followincertify that in the performance of the work for which this permit is issued, . shall not g: "I employ any person in such manner as to.become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature f certifies the following: "I certify that"in the performance_of.the work for which tWs.permit-is.issued,-Lshall employ parsons subject to workman's compensa- tion laws of California." `v r The applicant must call for all re ire inspections. Complete drawing on reverse side. x F Date: r' Signed X Titlen t F R EPARTMENT,USE ONLY ... .4 Area Application Accepted by Date 3l Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk_486-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 836-6385 j > AQplicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 t f ! _ .� i FEE AMOUNT DUE r AMOUNT REMITTED — r CASH 3 RECEIVED BY DATE. PERMI'T'NO I 4 INFO ' + EH 1324)REV.t/e 51 1 EH 14-26 to t