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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 VYEAR FROM DATE ISSUED � H�"� (Complete in Triplicate) r E �l� Application is he+eby made to the San Joaquin Local Health District for a permit to construct and/or install the work�he{{�eii+;decribed. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules anff)Tegulations of the San Joaquin Local Health District. Jab Address �� 7 / f`/ c City'` Lot Size PM Owner's Name ` 1 Address Phone Contractor Address License No. 04 5117 � Phone' . TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACE NT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR A,- 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 Q industrial ❑ Open Bottom W ❑ Manteca pia- of Well Excavation Dia- of Well Casing ,Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications y I`] Public_ Cl Other 0 Delta Depth of Grout Seal Type of Grout I ! Irrigation __Approx� Dept l I Eastern Surface Seal Installed by Pun _ Repair Work Done ❑ Type of Pup H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth y�,�2� ' Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 11 -REPAIR/ADDITION l I DESTRUCTION # I (No septic system permitted if public sewer is F , }#t available within 200 feet.) Installation will serve: Residence_ Commercial Other" Number of living units: Number of bedrooms _IN Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK EIType/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ _.R Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size r - FILTER BED ❑ Distance to nearest: Wel{ Foundation Property kine SEEPAGE PITS I I Depth Size Number SUMPS.( �_. -. ..❑;_.Distance.to nearest: .:_.. Well ,Foundation-.Property..,.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. Homeowner 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: ertify that in the performance of the work for which this permit is issued, l shall employ persons subject to workman's compensa- tion laws of Californi The applicant must I all r i inspections. Complete drawing on reverse side. Signed X Title: Date: r�/ �� FOR DEPARTMENT US ONLY -- Application Accepted by Date Area 16-3 Pit or Grout Inspection byDate Final Inspection by Date Additional Comments: t ID Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Envirorimentat Health Permit/Services 1601 E. Hazelton Ave„ P.O. Box 2009, Stk., CA 95201 FEEi INFO AMOUNT DUE AMOUNT REMITTED GASH RECEIVED BY DATE PER7MIT'NO, + EH 13-24(AEV.1i45) � \cam _ EH 14-26