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�y l APPLICATION FOR PERMITN 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) Prt-,,.h• �I+;�.�> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work her escfibed,,This-application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and th Rrrles and Regulati6ns of the San Joaquin Local Health District. �fW,� ,;Y Job Address d ��' '�✓�� City � Lot Size PM Owner's Name Address Phone O!/ ' Contractor Address . License No.-&, — Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REP[AcEmEwf ❑ DESTRUCTION ❑ PUMP INSTALLATION ,� SYSTEM REPAIR OTHER ❑ 4 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE I1 _ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS l ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ^DOmestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications NS } M Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I i Irrigation --Approx. Dept i I Eastern Surface Seal Installed by - Repair Work Done 2( Type of Pump H.P. L� State Work Done _ R Well Destruction ❑ Well Diameter Sealing Materia Itop 501 Depth Z!6 Filler Material (Below 5011 TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION l I DESTRUCTION l I 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 r le s 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 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 )} l SEEPAGE PITS I 1 Depth Size Number .w SUMPS __ , LIDistance to nearest:, Well , Foundation Property Line �F _ ;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. Horne owner or licensed ent'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 tic manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the followin : "I erti y hat in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of Califor i The applicant m II r all r qu' nspections. Complete drawing on reverse side. Signed X Title: �� Date: FOR DEPARTMENT USE O LY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT EMITTED CK RECEIVED BY DATE PERMIT-NO. IN �� CASH + EH 13-24 IREV.1/n 51 4 l i(� /—A Q EH 14-26