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APPLICATION FOR PERMIT' SAN JOAQUIN LOCAL HEALTH DISTRICT � 1601 E. HAZEL T ON AVE., STOCKTON, CAS JO Telephone 466-6781 PERMIT EXPIRES 1 YEAR}F OM DATE ISSUED ��4T {Complete in Triplicate} '��IC��. 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.. p �Y Job Address S- / l� PM ity of Siz j Owner's Name Address Phone ,? Contractor's Name ' 3� icense No. Phone TYPE OF WELL/PUMP: �`�NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ -^ DISTANCE TO N EARESTr SEPTIC TANK SEINER LINES DISPOSAL FLD. PROP. LINE' w' } FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF-WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS'----' t x , ❑ Industrial,/ ❑ Op�en'Bottom,, ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 0 ❑ Domestic/Private [I Gravel Pack Type❑ Tracy Te of Casing Specifications J � 1 ❑ Public Q�Other. ❑ Delta Depth of Grout Sea! �7ype of Grout © Irrigation / __-,A6prox. Depth ❑ Eastern Surface Seal Installed by t Repair Work Done EJ %Type of Pumps H.P. State Work Done o r ` # Well LJ Well`Diamefei_r Sealing Material (top 50'1 Depth / �'" �" Filler Material (Below 501 ��• TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is ' f `� �;��' + � �.,. available-within-200 feet.) Installation will serve: Res' ence t f Commercial_-Other -jam Number of living units.-. kNumber of rooms. Character of soil to a depth of 3 feet: f r`' Water table depth SEPTIC TANK, ` 1 T ype/Mfg, -C-/? P Capacity 2 No. Compartments PKG. TREATMEN_T PLTEl Method of Dis os I l s Distance to nearest: Well ; Foundation Property Line ` -- —.._-i ._._- ..r- •- - - - OF 1 LEACHINGIINE 4 No. & Length of lines _ Total length/size FILTER BED ❑ Distance to'nearest: "Well- Foundation Property Line Aln Ly- l i SEEPAGE PITS ❑ Depth Size— "_ Number C _SUMPS Distance to nearest: Well_- Foundation-3&2 — Property Line y (? DISPOSAL PONDS © 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 sutrcontracting 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 Californi s , The applicant mus ca or all required i pections. Complete drawing on reverse si i R =�2a � Signed Title: .Date: f FOR DEPAR ENT USE ONLY 7� , Application Accepted by ✓v Date '01 Area k .Pit or Grout Inspection by Date Final Inspection b Date4-2 Additional Comments; —ErStk-7466=6781--❑-Lodi x369-3621•— O Manteca--823-7104-- -0 Tracy 835-6385 Applicant Return all'copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.; CA 95201 FEE INFO "AMOUNT DUE 'AMOUNT REMITTED CASH CK RECEIVED LAY DATE PERMIT'NO. +EH1}2q(REV.10183i p l EH 14-28