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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA i ' A 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 District. 9 City Lot Size PM Job Address �i Phone Address a Owner's Name q` ` ^ � I� �Wr_ � Phone ,` /Contractor.� Address SQ r'1 License Nom r TYPE OF WELLlPUMP: Ir NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR LI OTHER ❑ il yIN s DISPOSAL FLO. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES e 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 El Domestic/ of Casing Domestic/Private ❑ Gravel Pack ❑ Tracy 9 Specifications F] Public n Other�� F1 Delta Depth of Grout Seal Type of Grout — I I Irrigation -Approx. Depth 1 1 Eastern, Surface Seal Installed by Repair Work Done C7 Type at Pump H.P. State Work Done _ Well Destruction ❑ Weil Diameter Sealing Material Itop 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK:- NEW INSTALLATION l 1 REPAIR/ADDITION I 1 DESTRUCTlONK INo septic system permitted if public sewer is available within 200 feet.i Installation will serve: E Residence_ Commercial ,. Other k Number of living units: Number of bedrooms ! �f Il Character of soil to a dept of 3.feet: Water table depth SEPTIC TANK -Jd TypelMfg Capacity No. Compartments r PKG. TREATMENT'PLMethod of Disposal AT. ❑ � / � Distance to nearest: Well TM Foundation . Property Line 2 � LEACHING LINE ElTotal length/size iNo. & Length of lines 9 l \ FILTER BED ❑ Distance to nearest: Well _/ Foundat ion Property Line f SEEPAGE PITS l 1 Depth Size Number I ^ SUMPS Ll 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 f rules and regulations of the San Joaquin Local Health Diktrict. t Home owner or licensed agent's signature certifies the fallowing: "I certify that in the performance of the work for which this permit is issued, I shall not s 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,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all requkpd inspections. Complete drawing on reverse side. Signed X Title: =_ :a!� Date: F ENT USE ONLY r I.vl i Application Accepted b i . Pate Area APP p y I� n ' Date�� Cj Pit or Grout Inspection by Date Final Inspection by r� Additional Comments: o .� ❑ Stk 466-6781 '+ ❑ Lodi -3621 ❑ Manteca 823-7104 Ca Tracy 835-6385 Applicant- Return all copiesyto: Environmental Health Permit/Services 1601 E. Hazelton Ave„ P.O. Box 2009, Stk., CA 95201 PEE AMOUNT DUE AMOUNT REMITTED, CASH RECEIVED BY DATE PERMIT NO. INFO }} %] +.EH 13-24IREV.1/"5) t EH 14-26 ~ -