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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA 14 Telephone (209) 466-6781 l PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r (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 i Local Health District, 71 Job Address City Lot Size PM Owner's Name d ss Phone 45 Contract Address License No. Phone 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 11 Public 11 Other ❑ Delta Depth of Grout Seat Type of Grout I 1 Irrigation --Approx. Depth 1.1 Eastern Surface Seal Installed by _ Repair Work Done 12 Type of Pump H.P. State Work Done_ l Well Destruction__=Well'Diameter Sealing Material Itap 50'i ? Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION' REPAIR/ADDITION 1.1 DESTRUCTION l I [No septic system permitted if public sewer is available within 200 feet.i Installation will Serve: Residence_ Commercial_, ether .. Number of living units: Number of. drooms r Character of soil to a depth of 3 feet: r� Water table depth SEPTIC TANK ❑ Type/Mfg a " Capacity No. Compartments PKG. TREATMENT PLT. ❑ f MethodofDisposal . Ile Distance to nearest: Well �6� Foundation Property Line ' LEACHING LINE M,1 No. & Length of lines Total lengt#i/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS Depth a Number Sl1hRP5j Cl Distance to nearest: Well-14-0—Foundation -ICZ Property Line.- ' DISPOSAL PONDS ❑ i 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 Di hitt. ;, __ t e y ,I-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 l employ any person in such manner as to become subject to workman's compensation laws of'Caliiomia."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 f call require ins c ions. Complete drawing on reverse side . r .,Signed X' € • Title: _ (a/ wn Date: �0'" a EPAIRTMENT USE-ONLY Application Accepted by Pit or Grout Inspection by Date Finel'Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 El23 Manteca 8 -7104 ❑ Tracy 836 6385 ~` i Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 > t )NFO FEE AMOUNT DUE AMOUNT'REMITTED CASH RECEIVED Ely'— � DATE PERMIT•NO. �.EH 13-241t1EV.rise) /� -'�101' /f --_"""�"'" EH 1126 /y 1r � x6