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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 TripkcatO Application is#leieby 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 comp iance with San Joaquin County Ordinance No. 549 for sewage or No, 1862 for well/pump and the Rules and Regulations of the San Joaqurr) Local Health District. Job Address _ _.. City Lot Size PM Owner's Name ................----- -__......... _ Address ---- .............-- —...- ........ Phone _..._ __...- Addif:s3 _ _License No. _. Phone TYPE OF WELLIPUMP: NEW WELL '. WELL REPLACEMENT _J DESTRUCTION (....i PUMP INSTALLATION L' SYSTEM REPAIR i..1 OTHER U DISTANCE TO NEAREST: SEPTIC TANK .............. SEWER LINES __.._.._ DISPOSAL FLD..-_ PROP. LINE FOUNDATION .-......_.................... ..__- AGRICULTURE WELL OTHER WELL __....__.. PITS/SUMPS _-- INTENDED USE TYPE OF WELL PROBi EM AREA CONSTRUCT ION SPECIFICATIONS ----- - - ........ - - - - ......... L Industrial L. Open Bottom Manteca Dia. of Well Excavation __ Dia. of Well Casing _ i Domestics Private f -1 Gravel Pack L Tracy Type of Cas-rig_._-__._.....................__. Specifications Public #.l Other :' Delta Depth of Grout Seal -___ --- ......... Type of Grout__.._....__ Irriganon Approx. Depth 1 Eastern Surface Seal Installed by - Repair Work Done L Type of Pump _- H P. ___..,. .------..-- - State Work Done ._- ----__ WeV Destruction I Welt Diameter Sewing Material (top 50') Depth Filler Material {Below 50') TYPE OF SEPTIC WORK NEW INSTALLATION i. 1 REPAIR, ADDITION ', I DESTRUCT#ON •. (Na septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commerciai Other - Number of living units: Number of bedrooms Character of soil to a depth of 3 feet': _--._.------ ___ - -.---- Water table depth SEPTIC TANK 1 1 Type/Mfg ___. Capacity .._ _ No. Compartments PKG- TREATMENT PLT- 1 1 Method of Disposal Distance to nearest: V^Jell_ ___ Foundation Property Line LEACHING LINE # 1 No. & Length of lines ________ Total length/size FILTER BED I Distance to nearest Well Foundation __._.._..._._...—. Property Line _ SEEPAGE PITS Depth -_ Size .. _ -----.-- ----_-----..... Number SUMPS t Distance to nearest: Well _ Foundation - Property Line DISPOSAL PONDS 1 1 1 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 Di"strict. 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 taws of California." The applicant must call for all required inspections. Complete drawing on reverse side. Signed X-,-_..-_„_-_ Title: - --,. .................................. _..-------- ate: FOR DEPARTMENT USE ONLY Application Accepted by _._ Date ..__ Area Pit or Grout Inspection by ____- Date .................--- Final Inspection by Date Additional Comments: U Stk 466-6781 0 Lodi 369-3621 Ci Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT�NO. EH 13.24(REV,i n s� EH 1428