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_ 4 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH"DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA l Telephone (209) 466-6781 f PERMIT EXPIRES TYEAR FROM DATE ISSUED i (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. 1B62 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. ` Job Address City Lot Size PM Owner's Name �i Address Phone vey�'.r'd Gc'/J a.P'?� ' y " tea 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 FOUNDATION t .AGRICULTURE_WELL,,T.._-.._— OTHER WELL PITS/SUMPS INTENDED TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open ❑ Manteca {. Dia. of Well Excavation' Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy- Type of Casing Specifications I 1'1 Public ❑ Other ❑ Delta ' Depth o eal Type of:Grout i I I Irrigation �..Approx. Depth I 1 Easter`n7 Surface Seal Installed Repair Work Done ❑ Type cot Pump I 'H.P. # State Work Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') ' TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR'/ADDITIO +DESTRUCTION l I (No septic system permitted if public sewer is i available within 200 feet.) s a 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. ❑ I Method of Disposal Distance to nearest: Well Foundation Property Line a ' LEACHING LINE No. & Length of lines < < T Total length/size Ftp` e -�.... _ __ . -� -._ �fs-_ FILTER BED ❑ Distance to nearest: WeA Foundation Property Line SEEPAGE PITS I I Depth • Size Number r SUMPS ❑ Distance to nearest: Well Foundation Property,tine DISPOSAL PONDS ❑ k 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 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: "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." 1 , The applicant must c Xr all require . Patti complete drawing on reverse side. Signed X zip Title: Date: FOR.DEPARTMENT USE ONLY / Application Accepted Date Z 1 Area Pit.or Grout,lnspe ion Date Final Inspection by Date Additional Comments:, ❑ Stk 466-6781 ❑ Lodi 369-3621,` `a. ❑ Manteca 823=7iO4 , '-0 Tracy ,835-6385 ` Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave.,•P.O. Box 2009, Stk. CA 95201 h FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH + EH 13-241REV.eiHsf -d EH 14-2e