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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hateby 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.548 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job AddressCity �C Lot Size PM Q Owner's Name j /K Address Phone Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 4'* FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE . TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack LJ Tracy Type of Casing Specifications F1 Public x C7 Other 71 Delta Depth of Grout Seal Type of Grout I I Irrigation ----Approx. Depth i I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 50') I Ni Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATIO REPAIR./ADDITION l I DESTRUCTION l I (No septic system permitted if public sewer is S available within 200 feet.) Installation will serve: Residence Commercial Other Number of living units: Number of droo Character of soil to a depth of 3 feet: 1 Water table depth 41 [� SEPTIC TANK )l!L Type/Mfg -.•r _ Capacity�j7�� No. Compartments PKG. TREATMENT PLT. ❑ >l g Method of Disposal Distance to•nea�ett: Well /K29 Foundatio`ri-�` - —Property Line -- �---- —T�— LEACHING LINE ❑ No. & Length of lines Total length/size 3 FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 1 1 Depth Size 3 Nurtiber u 20 SUMPS Distance to nearest: Welt 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 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."Contractor's hiring or.sub-contracting signature cartifies.the following: "1 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." t The applscanst call for I require inspec ions. Complete drawing on rave side. + �•� Signed X —. Title: Date: 1._-15_e19 R DEPARTMENT USE ONLY Application Accepted by Date / +t Area -Pit or Grout Inspection by Date Final Inspection by Date �G Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 - ❑ Manteca 823-7104 ❑ Tracy 835-6385 1 Applicant - Return all copies to: Environmental Health Permit/Services 1601'E:'Hateltor Ave.,, P:O."86x 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMFT-NO. INFO . w ♦.EH 13-24(REV.i i H 5) - --�. r_.,,,...- ,. A B/ EW 14-28^-.. n �Z`l �+