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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209) 466-67$1 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 Regulatibns of the San Joaquin Local Health District. ] 1 Job Address • City 3'"r 5�� Lot Size PM Owner's Name I:. ('^ 10 4 d PT Address S/��i�l Phone Contractor Ifl i�W-4.. u 11L t Address fV �e 1L' &, License No. Phone T' TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT El DESTRUCTION ❑ 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 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ('I Public M Other 17 Delta Depth of Grout Seal Type of Grout _ I I Irrigation --Approx. Depth" -13{astern-- _ "Surface Seal.installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION' REPAI�fiADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is / available within 200 feet.) Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet-. CA -- - - — Water table depth SEPTIC TANK U Type/Mfg C-04• 2(A Oct l Capacity No. Compartments PKG. TREATMENT PLT. ❑ 1F' f Method of Disposal Distance to nearest: Well 4 Foundationb.._._ _ Property Line �h LEACHING LINE O No. & Length of lines Total length/size �I FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS w l I Depth Size T Dumber SUMPS Distance to nearest: Well�.�s Foundation .5 � � 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 Di%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 not . employ any person in such manner as to become subject to workman's compensation laws of California." Contractors hiring or subcontracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, ].shall employ persons subject to workman's compensa- tion laws of California." -- - - --- The applicant must call lffor`all r wired inspections. Complete drawing on reverse side. n Signed X_ Title: � .t- Date: FOR IDEPARTMET USE ONLY EE Application Accepted by Date Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑"Sfk 456-6781 ❑ Lodi 363-36:fff ❑ Manteca 823-71(64 + V ❑ Tracy a35-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO "AMOUNT DUE AMOUNT REMITTED CASH CK 11 RECEIVED BY DATE b PERMIT"NO. ♦ EH 13-24IREV.1/8513 �6D ` � }[1T `r.[ / 93- / EH a-26 '�Jl L [ 1 y