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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 4 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 a Local Health District. nd Regulations of the San Joaquin Job Address C r City Lot Size PM , Owner's Name r rens _J SSS - Phone 3 "' U' Contractor's Name' �i� L ense No./ Phon TYPE OF WELL/RUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR � OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL! PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications aQ ❑ Public ❑ Other t ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation _.-Approx. Dep ❑ Eastern Surface Seal Installed by � Repair Work Done Y Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter f Seating Material (top 501 Depth Filler Material'IBelow 501 , TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is 1' available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: I Water table depth i SEPTIC TANK Ll Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ °-`,`1 ; 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 ' r SEEPAGE PITS ❑ Depth I Size `� " 4 Number SUMPS ❑ Distance to nearest: Well Foundation Property Line > DISPOSAL PONDS ❑ hereby Lcartify that I Piave 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 fallowing: "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." The applicant t cal or all requir inspections. Complete drawin reverse side. < Signed X itle: Date: FOR DEPARTMENT SE ONLY Application Accepted by Date 0 _W Area 12.- Pit or Grout Inspection by Date Final Inspection by Date +� Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 FEE AMOU INFO NT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'N0. + EH 1324 MEV.10/831 �� li EH 14-28 �. C+ .. - AFS-Li yZb c