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APPLICATION FOR PERMIT ` SAN JOAQUIN LOCAL HEALTH DISTRICT 3 199 1601 E. HAZELTON AVE., STOCKTON, CA Alt >��A�� Telephone (209) 466-6791 ENVIR�NMEN-TA PERMIT EXPIRES 1 YEAR FROM DATE ISSUED QERM��SER�ICES (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 Rulas'and Regulations of the San Joaquin Local Health District. Job Address City Lot Size PM CAR 1' Address � r ,V� Phone Owner's Name , r_-r�-T---� , Fo� Address td r License No. Phone ContractorUP ; 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 i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �/ 7 ❑ Industrial ❑ Open Bottom F1Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 0 FI Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout i I Irrigation —.-Approx. Depth l I Eastern Surface Seal Installed by - Repair Work Done'. ❑ Type of Pump H.P. State Work Done Well Destruction Well Diameter Sealing Material (top 501 — V Depth_ f Filler Material (Below 50') TYPE 51F OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTION I i (No septic system permitted if public sewer is 1-4 available within 200 feet.) Installation will serve: Residence Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: - Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines` 7 Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS J l I Depth Size Number SUMPS jJ Ll Distance to nearest: Well Foundation Property Line r -DISPOSAL PONDS—`0 i _ 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. f 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' s ch manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the follow- g: 'I certify that in the performance of the work for whichrthis permit is issued, I shall employ persons subject to workman's compensa- tion laws of r The applican call for all requir d nspections. m to drawing o v s side. M f Signed X Title: - Date: FO 0 PARTMENT USE ONLY L Application Accepted by Date v Area ate Pit or Grout Inspection b Date Final Inspection by O d s c pe Y Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 836-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E, Hazelton-Ave,,-P.O._Box 2009, Stk.,-CA 95201 FEE AMOUNT DUE AMOUNt REMITTED CK INFO CASH RECEIVED By DATE PERMI7'NO. ..EH13-24(REV.I/X5) O 7� _-2,1q . j EH 14-28