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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES rt 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. �/ City �.� Lot Size PM Job Address /12 ddress _ Q Owner's Name 67 'T Phone t Contractor Address - r, `License No.'s Phone_ TYPE OF WELL/PUMP! NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION LI PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ M ` DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK- SEWER LINES FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing a Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation m -Type of_Casin - - - — ❑ Domestic/Private ❑ Gravel Pack - ❑ Tracy � YP gSpecificationsT e of Grout - t"1 Public Cl Other '�,,, ❑ Delta ! Depth of Grout Seal yp E - I I Irrigation _.-Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Dane ❑ Type of Pump H.,P, State Work Done Well Destruction ❑ Well Diameter Sealing Material'itop 50`I Depth Filler Material lBelow 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUC N I i lNo �within �t �itted if public sewer is availab Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Water table depth Character of soil to a depth of 3 feet: Wa p SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments ' 4 Method of Disposal s PKG. TREATMENT PLT. ❑ k " { % -A Distance to nearest: Well Foundation ;Property Line" � < r _ LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line "t SEEPAGE PITS ( I Depth Size NumberI t . SUMPS L� Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ # 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.Di1tr.ict._--`-^- -- •- 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 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=ccom pensa- tion laws of California." I The applicant must tail for all required nspections. Complete drawing on reverse side. i Title: Datea� Signed X FOR DEPARTMENT USE ONLY �[ F Application Accepted by Date r Area �. Date Final Inspection by Date ' All Pit or Grout Inspection by 4 /C Additional Comments: r ElStk 466-6781 Lodi 36.9-3621 LJ 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 5S FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. INFO ♦.EH 13-24 IREY.1/x 51 EH 14-26 ' f