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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 1 YEAR FROM DATE ISSUED i (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 f 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 r / Lot Size PM dJ "G Owner's Name - Address Phone WAY ContractoAddres f L4cense No. Phon TYPE OF W LL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION © .,� SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK `SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTUREWELLOTHER WELL PITS/SUMPS 4 INTENDED USE TYPE OF WELL PROBLEM AREA + CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications r I1 Public f7 Other 1:1 Delta Depth of Grout Seal Type of Grout I I irrigation t _Approx. Depth I I Eastern Surface Seal Installed by I Repair Work Done ❑ Type of Pump H.P. State Work Done _ -Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 F TYPE OF SEPTIC WORK: NEW INSTALLATION (I RLPAIR/ADDITIONDESTRUCTION I I (No septic system permitted if public sewer is i fr available within 200 feet.) Installation will serve: Residence yA' - Commercial Other TIN Number of living units: —/— Number of bedrooms -_5__,__ �} 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 �0(1 No. & Length of lines Total length/size FILTER BED Q Distance to nearest: Well Foundation Property Line-_S:f SEEPAGE PITS I 1 Depth Size. Number SUMPS ❑ Distance to nearest: Well - .•Foundation r , 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, an rules and regulations of the San Joaquin Local Health D?:trict. 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 no 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 req ed i spections. Complete drawing on reverse side. Signed XTit[e: /C►�, F DEPARTMENT USE ONLY ff Application Accepted by "~ - Date 4 �^ Area A Pit or Grout Inspection by _ Date Final Inspection by Date Additional Comments: ❑ Stk 486-6781 1-1Lodi 369-3621-- ❑ Manteca 823-71D4' ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE MOUNT DUE AMOUNT REMITTED � CK RECEIVED HY DATE PERMIT'NO. INfO CASH + EH 13-241REv.1/8n5 t o` 16 for EH 14-26