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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT t 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 11-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 City Lot Size PM Owner's Name �. � Address • Phone r 1 �! h _Cddress` .1� 7 R� Contractor A ��`��° � License No. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT © DESTRUCTION ❑ f PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE F FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS � 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 ❑ Public C) Other ❑ Delta Depth of Grout Seal Type of Grout _ I f lrrigation -Approx. Depth I 1 Eastern Surface Seal Installed by t Repair Work Done ❑ Type of Pump t Y s4 H.P. State Work Done Well Destruction El Well Diameter F Sealing Material )top M1 _ Depth Filler Material-(Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION i !ADDITION CTION l I (No septic system permitted if public sewer is I J--. - ... .,.. . available within 200 feet► Installation will serve: Residence �I1175 mercial— Other Number of living units: t Number of bedroPms E t� Character of soil to a depth of 3 feet: C Water table depth SEPTIC TANK 9,+MgM'♦g Capacity No. Compartments t PKG. TREATMENT PLT. ❑ iMethod of Disposal n Distance "nea�est�""'�We11""^� Foundation Property Line }� r b t...l � LEACHING LINELsZ_Pi�ffi Length of lines '~ Total'lengthlsize YD FILTER BED ❑ Distance to�nearesv Well . Foundation ' Property'L'ine SEEPAGE PITS wf—'6.pth Size. — Number SUMPS ❑ Distance to nearest:' Well Foundation Property Line DISPOSAL PONDS ❑ f ' 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§trict. 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 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 followin : "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 la f Califor a. The applicant call for I r wired s e drawing on re erse si Signed Title: Date: T FOR DEPARTMENT USE ONLY 7 Application Accepted by N Date v� Area Pit or Grout Inspection b ate C U ]Final Inspection by – Date a Additional Comments: Q k ❑ Stk 466-6781 ❑ Lodi 69 3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 j Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 IFEE NFO AMOUNT-DUE AMOUNT REMITTED i CASH RECEIVED 9Y'� DATE PERMIT NO. qt.EM 13-26 IREV.1(x 51 EH 1�-Ta