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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 12091 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. 71�/� !/ Job Address Ie � ' b v City. Lot Size PM Owner's Nam LWAddress Phone Contractor Address—qg i -•License No.7 S Phone r TYPE OF ELL/PUMP: NEW WELL.❑ WELL REPLACEMENT ❑ DESTRUCT PUMP INSTALLATION,❑ �r SYSTE R PAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK i i SEWER LINES _ DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Auustrial v. rl Ppen Bottom 1-1MantecaDia. of Well ExcavationF + Dia. of Well Casing mestic/Private, �L EJ Pack El Tracy Type of Casing- Specifications blic ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material {Below 501 1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIO No septic system permitted if public sewer is I ble within 200 feet.) v Installation will serve: Residence_ Commercial_ IOther (y Number of living units: Number of bedrooms t y owl 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 near�esWell Foundation Property Line LEACHING LINE ❑ No. & Length of lines t Total length/size 1 a 1 FILTER BED ❑ Distance to nearet t:14 Well_�___.__".__"._ Foundation Property Line SEEPAGE PITS ❑ 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. s w 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 became 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 ornia." The applic t m st c r uired in tions. C plete drawing on r rse s 1 Signed < t Title:_. �/- Date: C1 (9 R DEPARTMENT USE ONLY Z, Application Accepted by Date `! �at, Pit or Grout Inspection by Date I pection by Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8354M 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 K RECEIVED BY DATE y�PERMIT'NO. t EH 13241REV.t/as) ��- �J �O �I O C}`�Sb EH 1426