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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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 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. 61w7, City Lc r Lot Size�7 1 PM Job Address Owner's NamePhone Address` Contractor r7U�[ Address U License No. Phone TYPE OF WELL/PUMP: NEW WELL LJ WELL REPLACEMENT'❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ �, SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Wel! Casing ❑ Industrial ❑ Open Bottom - L] Manteca - Dia: of Well Excavation ❑ Domestic/Private d Gravel Pack ❑ Tracy Type e of Casing - Specifications ❑ Public n Other ❑ Delta Depth of Grout Seal Type of Grout r 1 1 Irrigation _..Approx. Depth i I Eastern Surface S"eaf,installed by:±' Repair Work Done ED Type of Pump H.P. "" State Work Done_- N Well Destruction ❑ Well Diameter Sealing Materiel itop 50') pQ' Depth Filler Material-(Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION V REPAIR/ADDITION.l 1 DESTRUCTION i I (No septic system permitted if public sewer is S { available_within 200 feet.) r ,r installation will serve: Residence" Commercial_ Other Number of living units: Number of bedrooms. + i Character of soil to a depth of 3 feet: - - Water-table depth SEPTIC TANK L Type/Mfg =� eii,,-c Capacity No. Compartments PKG. TREATMENT PLT. ❑ f Method of Disposal Distance to nearest: Well Foundation�.._--_Property Line' ineLEACHING LINE syr No. & Length of lines — �Q Total length/size FILTER BED ❑ Distance to nearest: Well Foundation . Property Line" i SEEPAGE PITS I I Depth Size Number- r SUMPS 0 Distance to nearest: Well- Foundation Property Line DISPOSAL PONDS ❑ 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 Di§trict. Home owner or licensed agent's signature certifies the following: "1 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 must call for all required inspections. Complete drawing on reverse side. a Signed X Title: Date: FOR DEPARTMENT USE ONLY 4 .- Application Accepted by Date 13 Area Pit or Grout Inspection by Date Final Inspection by Da ` Additional Comments: IE ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7.104 O Tracy 835-6M5 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 3 j FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO /� �. +.EH13-241REV.tia5Y �(f tos- EH 14-2a6 -