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APPLICATION FOR PERMIT l� SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) I� 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 r Local Health District. I q q C�+� City `410 L Lot Size �( PM Job Address ' r p1 . Address Q S a- ®� Phone 9 owner's ner's•Name v �� C Address ` C�l�f License No. Phone Contractor TYPE OF-WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 1� PUMP INSTALLATION 71 SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP- LINE FOUNDATION —AGRICOL-T-URE-WELL-Y-�----- OTHER WELL PITS/SUMPS I� INTENDED USE -? TY.PE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 4 ❑I Industrial ❑ Opem Bottom-` ❑ Manteca � Dia- of Well Excavation Dia. of Well Casing ,r Type ofCasing t Specifications Ll Domestic/Private E1 Gravel!Pack Ll Tracy :yp ; �_ g I kn Other x~l=1 Delta Depth of Grout Seal Type of Grout l`1 Public h Approx. Depth I 1 Eastern Surface Seal installed by 1 Irrigation — p Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material {top 501 ? w„ �' Depth � 4` - - filler Material (Below 50') -- �- 7YPE OF SEPTIC WORK: NEW INSTALLATION' REPAIR/ADDITION I I DESTRUCTION I l iNo septic system permitted if public sewer is i, available within 200 feet.). Installation will serve: Residence CommercialOther Number of living units: Number of b ro m Character of soil to a depp of 3 feef:�. _ all- tater table depth Q Capacity �t O ` SEPTIC TANK Type/Mfg �1 No. Compartments" PKG. TREATMENT PLT. ❑ Method of`Di�s��I Distance to nearest: Well Foundation Property Line LCL I " 6 Total length/size LEACHING LINE No. & Length of lines FILTER BED 19V— ❑ Distance to nearest: ell Property Line .._ `f -J Sizu�� Number SEEPAGE PITS Depth r SUMPS ❑ Distance to nearest: Well Foundation Property Line "'': n + DISPOSAL PONDS ❑ it 1 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 District. 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, 1 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- r tion laws of California." M p he applica or II i d i Pett ons. Com t rawing on rev rs)�a side- Signed X C Title: Date: 0� i R DEPARTMENT US ONLY I Application Accepted by r�1�-��`�-'�^^�� `�� Date �� Area ,l Date Additional Final Inspection by - Dat U Pit or Grout Inspection by 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 4 CK 4 FEE r I INFO AMOUNT DUE AMOUNT REMITTED SH RECEIVED BY DATE PERMIT NO. +.EH 13.24(REV.t IH 5) OS S tJ I EH 1428 iN'