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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 f (Complete in Triplicate) 4 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 wel!/pump and the Ryles and Regulations of the San Joaquin Local Health District. p i Job Addre City Lot Size l PM a Owner's Nam Address - Phone —2550 i,. Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT-O' DESTRUCTION ❑ I PUMP INSTALLATION C1 TEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK w SEWER LINES DISPOSAL FLD. PROP. LINE " y FOUNDATION " "' a AGRICULTURE WELL OTHER WELL PITS/SUMPS 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 j ❑ Public [__1 Other , ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --:,Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter a s Sealing Material (top 50') Depth r Filler"Material (Below 501 (� TYPE OF SEPTIC WORK: 'NEW-INSTALLATION ❑ REPAIR/ADDITION C-1, DESTRUCTION ❑ (No septic system permitted if public sewer is w Iavailable within 200 feet.) Installation will serva: Residence ' aComme7cial a= ".Other , Number of living units: Number of bedrooms Character of soil to a depth of 3 feet. `°' Water table depth SEPTIC TANK ., TypelMfg � ity � 7 No. Compartments PKG. TREATMENT PLT. ❑,'� // fy Method of Disspp sal Distance to nearest:,. Well /�Q J Foundation �� Property Line 1� LEACHING LINE No. & Length'of lines " ' otal length/size— FILTER ength/size FILTER BED El Distance to nearest;* Well W Foundation Vol Property Line SEEPAGE PITS EJ Depth Depth Size VVV SUMPS ❑ 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 District. 'j 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 ih 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 a or all required inspections omplet rawing on reverse side. I �JLvJ{/-e, / Signed °Title: Date: F DEPARTMENT USE ONLY 131 Application Accepted by Date / f Area Pit or Grout Inspection by ate Final Inspection by �� Date Additional`Comments: a ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 FEE AMOUNT DUE AMOUNT REMITTED ._ K RECEIVED BY DATE PERMIT`NO. INFO �y 51 �p/yam + EH 13-24{REV.1/65) 7r LSA �"� �'..,{. / •~ _� �� , / ��`� EH 14-26 i '