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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hoieby 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 �+ !+? 1 t �� CityGL Lot Size PM Owner's Name Address Phone ContractorAddress 80 60Y 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 FLO. -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 t © Domestic/Private ❑ Gravel Pack ❑(Tracy P'. Type of Casing Specifications ❑ Public (7 Other 71 Delta Depth of Grout Seal Type of Grout I I Irrigation ---Approx. Depth I I[Eastern Surface Seal installed by Repair Work Done ❑ Type of Pump-, - i -H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION l I DESTRUCTION i I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Z Commercial y� Other Number of living units: I Number of he'dr Character of soil to a depth of 3 feet: �3� Water table depth SEPTIC TANK Type/Mfg ____ ��.' G�t}e►�� Capacity..� ��d�" No. Compartments s; PKG. TREATMENT PLT. ❑ J Method of Disyosal Distance to nearest: Well Q(2 Foundation e a Property Line LEACHING LINE IV""Nor & Length of lines U Totallength/size FILTER BED El Distance to nearest: Well f Kr Foundation_ "vroperty Line SEEPAGE PITS I I Depth i (Size Number SUMPS 0Distance to nearest:. Well Foundation Property Line DISPOSAL PONDS ❑ 3 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 District. l Home owner or licensed agent's signature icertifies,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[o!'wor&an's compensation laws of California."Contractors 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 for all required inspecttions. Complete drawing on reverse side. Signed X 1& 11• Title: F Lr�� " Date: FOR DEPARTMENT USE ONLY }. Application Accepted by Date r Area Pit or Grout Inspection by i Date Final Inspection b Datl� Additional Comments: ' ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 E1Tracy 835-6385 "Applicant - Return all copies.to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE CK Of INFO AMOVNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. " ...' A + EH 1&21 fREV tfnsl - EH 14-26-1