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1 S / APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED t. (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 ` City Lot Size PM n . + Owner's Name r Phone W Contractor , s� ddress � �� fGA.rGt 4,cense r�o. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ "' SYSTEM REPAIR ❑ OTHER E) -- DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHERiWELL 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 17 Other ❑ Delta Depth of Grout Seal. 1 Type of Grout _ t I Irrigation ---.,Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State'Work Done Well Destruction 0.- We'll Diameter _ ' Sealing Material (top 50') Depth --r-Filler Material I Below 50') ' n TYPE OF SEPTIC WORK: NEW INSTALLATION f'P REPAIR/ADDITION, DESTRUCTION [ I'.(No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other ! - �. '. Number of living units: -Number of bedrooms *Character of-soil to a'#depth of 3 feet: Water table depth .�.. SEPTIC TANK � Type/Mfg. �+�� [' _ Capacity_-__ _ No. Compartments PKG. TREATMENT PLT. 0W4. T ' At � € € Method of Disposal r _ Distance to nearest: Well Foundation 'r `Property Line V\) LEACHING LINE No. & Length of lines Total length/size f FILTER BED ❑ Qistance to nearest: Well-- 1 Foundatipn" � Property Line r - ,�';. �- -:r.e++r.!�•„-',.r+n...-wf:a�t.-r.w-...F� .._ -.- SEEPAGE PITS I i9 Depth 3 A-s�w�.,�.-«.rr,.-rcrSize ” Number SUMPS D Distance to nearest: Well.r� i Foundation t "Property Line j V DISPOSAL PONDS © , # 111`11 I hereby certify that I have prepared this application and that the-(work Will'be,d a in accordance with San Joaquin cbunty ordinances, state laws, and i. rules and regulations of the San Joaquin Local'Health Disttidt:s 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 Y employ any person in such manner as to become subject to workman's compensation law`s of California."Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance&the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." I The applicant must call for all'ie rt fired inspe i s. Complete drawing on reverse side. o Signed X Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by �. Date Area 1 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 95201 FEE CK INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. F 7f+ EH 13-24 IRE)/.t i x s7 ry EH 14-28 ��