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APPLICATION FOR PERMIT 7—vt, lQ- .A PP- SAN JOAQUIN LOCAL HEALTH DISTRICT n v 1601 E. HAZE 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 District. y� Job Address City Lot Size PM Owner's Nam Address Phone < RAS ; Contractor Address `� License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEME11T ❑ DESTRUCTION ❑ PUMP INSTA-LLATION CJ 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 Cl Gravel Pack ❑ Tracy Type of Casing Specifications CI Public i71 Other F1 Delta Depth of Grout Seal Type of Grout i I Irrigation --Approx. Depth i 1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK; NEW INSTALLATION 14REPAIR/ADDITION f I DESTRUCTION I 1 {No septic system permitted if public sewer is UR available within 200 feet.) Y r Installation will serve: Residence 4 Commercial Other Number of living units:O�,, Number bedroom.�� Character of soil to a depth of 3 feet: 6 Water table depth SEPTIC TANK I' Type/Mfg Capacity .er75h No. Compartments 171, PKG. TREATMENT PLT. ❑ / Method of Disposal Distance to nearest: Well,l,D� Foundation CO® Property Line X, LEACHING LINE Jl' No. & Length of lines JS 4n / Total length/size FILTER BED ❑ Distance to nearest: Well t Foundation Property Line� `t SEEPAGE PITS Depth Size _ Number SUMPS ❑ Distance to nearest: Well..1L60 J Foundation _ Property Line 14— 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: -11 certify that in the performance of the work for which this permit is issued, 1 shall not -employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting 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 must call for all inspe ons. Complete drawing on reverse side. Si Title: -- --- Date: J DEPARTMENT USE ONLY �I Application Accepted by Date . ,. _ Area ` Pit Grout inspection by Date Final Inspection b'� Date Additional Comments: // ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Sik., CA 95201 FEE INFO A OUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE _q (�PEERMIT'NO. + EH 13-24[HEV.ti ns) 0- r G [Ji�� J( J�/�J(D EH 14-26 V ` T fi° (f (Vl