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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 (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 D'is'ttrict. " j1 Job Address � �^ l J� (City (� Lot Size PM^f A Owner's Name _ d 1 V�Address Q 1 \. �J A11�`l� r Phone �Q O� 11 Contracto Address rl3 License No, Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ l PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION 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 171 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications i FI Public ❑ Other D Delta Depth_.of Grout Seal Type of Grout ---- I I Irrigation --Approx. Depth I I Eastern Surface Seal Installed by C Repair Work Done ❑ Type of Pump H.P. State Work Done I Well Destruction ❑ Well Diameter Sealing Material {top 501... Depth � ler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I] EPAI /ADDITION DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial Other I Number of living units: - Number.of b4Wrooms Character of soil to a depth of 3 feet: s1. ,w - Water table depth SEPTIC TANK ❑ Type/Mfg .� -Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well .-... Foundation Property Line rr�� LEACHING LINE K No. & Length of tines Ck© Total length/size Q of � ��r r FILTER BED C1 Distance to nearest: well=��0......_._ Foundation�._. Property Line 11CT SEEPAGE PITS i I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ t- -- 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§trice i 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 compensa- tion laws of California." The applicant ust call fa I re uired inspections. Complete drawing on reverse side. (� Signed X Title: ..._ :Y. Date: to I FOR DEPARTMENT USE ONLY Application Accepted by Date Z Area Z Pit or Grout Inspection by date Final Inspection bye Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ 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 DCK 4UE UUEE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. EH r EH 114-2e-2AfREV.t/x51 � 0// !