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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 (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct andlor 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. '' l Job Address d� �[/ Cit n �� Lot Size /GCZ?rAA_, PM Owner's Name Address 7 Phone Ir Contract Address 7� License fQoPhoneI A 1 11 0 TYPE OF WELL/PUM NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE " FOUNDATION AGRICULTURE OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM A CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ eca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack Tracy Type of Casing Specifications Irl Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation rax. Depth l I Eastern Surface Seal Installed by _ l Repair Work Done ❑ pe of Pump' H.P. State Work Done Well Destruction Well Diameter Y Sealing Material {top 50') Depth Filler Material (Below 50') _ TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I ] DESTRUCTION I I INo septic system permitted if public sewer is Iavailable within 200 feet.) r` Installation will serve: Residence L Commercial Other d Number of living units: J Number of bedroo ON Q Character of soil to a depth of 3 feet: Water table depth 4 SEPTIC TANK Cl Type/Mfg Capacity-A No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal y Distance to nearest: Well�� Foundation � Property Line s i LEACHING LINE No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: WeII oundation Property Line i 2� ` , 3 SEEPAGE PITS 11 Depth Size� Number ' SUIVIPS Ll Distance to nearest: Well_Z"-.(�'Foundation�1�} Property Line DISPOSAL PONDS ❑ z T' 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 D&rict. 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 mu call for all requir in pections. Complete drawing on reverse side. Signed X Title: Date: � y FOR DE ARTMENT USE ONLY Appl!cation Accepted by17 DareArea + Pit or Grout Inspection by Date Final Inspection by Date {�i i 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 INFO 1 AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERM17'NO. t EH 13-241REV.t/8 s) 11 EH 14-29 Q ,� 99RI q 3 6`71