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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT �rJ 1601 E. HAZELTON AVE., STOCKTON, CA J1 Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) �tn� Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the wo herein 3escri application �s made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations o*Vdj5Wquin Local Health District. 45-1r Jab Address G �� Cit Lot Size PM Owner's Nam f Address Phone Contractor Address s3GIt License N . d Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES SAL FLD. PROP. LINE FOUNDATION AGRICULT L OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PR AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Sotto ❑ Manteca Dia. of Well Excavation Dia. of Well Casing \ ❑ Domestic/Private ❑ G ato r ❑ Tracy Type of Casing - t Specifications Ll Public - Other ❑ Deltas Depth of Grout Seal Type of Grout--- S 11 Irrigation �_.-Approx. Depth t I Eastern� urface Seal Installed by Repair r done ❑ Type of Pump State Work Done _ Destruction CI Well Diameter Sealing Material,Itop 50:)� Depth Filler Material IBelow 50')'} " TYPE OF SEPTIC WORK: NEW INSTALLATION I'l REPAIR/ADDITION I I DESTRUCTION lNa septic system permitted if public sewer is r 1 vailable within 200 feet.) Installation will serve: Residence— Commercial— Other r Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth %SEPTIC TANK Q Type/Mfg —Capacity ' No. Compartments PKG. TREATMENT PLT. ❑ l I Method of Disposal Distance to nearest: Well Foundation Property Line ) LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line ' r ` SEEPAGE PITS I I .Depth Size; "; Number SUMPS ❑• Distance to nearest: Well Foundation Property Line I DISPOSAL PONOS ❑ t 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. j Home owner or licensed agent's signature certifies the following;-1 certify-that in.the-perfor ance 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 ust call for all required inspections. Complete drawing on reverse side. y Signed X Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date 7 / Dat �y Final Inspection by Date : �J7 J� ` NJ Additional Comments: �{ �� ` 3 ` 4 ' El Silk 466-6781 ElLodi 369-:%21 C3M nteca 823-7104 ❑ Tr vVUIL Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Waz B 1 f FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DAT~ PERM! NO. i INFO tI J kl Com, ♦ EH 13-24 Mev,1/"51 �.00 'C-9 C7 EH 14-26 i