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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 hereby made to the an 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. Job Address ' -� r ! r • City M0 Lot Size PM Owner's Name le r+ I>J Address /5177 Phone ContractorAddress •o• NA a License No Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ri DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. 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 F-1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications l'l Public n Other 171 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 Dane_ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1:1 REPAIR/ADDITION I I DESTRUCTION INo septic system permitted if public sewer is available within 200 feet.I { ]� Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments ` PKG. TREATMENT PLT. ❑ Method of Disposal J Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS ❑ 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 rules and regulations of the San Joaquin Local Health District. Home owner or lice d 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 an on such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature certifies t 1 i g "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 f I The applic t a I required inspections. Complete drawing on reverse side. Signed Title: Date: 47 FOR DEPARTMENT USE ONLY Application Accepted by Date /1—, Z Area / -3 Pit or Grout Inspection Data Final Inspecti y r Additional Comments: ko ❑ Stk 466-6781 ❑ Lodi 369.3621 Cl Manteca 823-7104 ❑ Tracy -6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 IEEEO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. + EH13-24(REV.I/H51 .�s-�, v [ 7�o 1(z-F� ��-3y�7 EH 14-2e