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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. t 4 JobAddress \ D oC 1'LLot Size`�� PM ly ., Phone 7 9— Owner's Name L Address l ��tt CC 1 ContractorAddress License No. Phone I 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 AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial Ll Open Bottom El Manteca Dia. of Well Excavation Dia- of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ 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 tBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ElREPAIR/ADDITION ElDESTRUCTION Ka o selabptic system ithin m rented if public sewer is Installation will serve: Residence— Commercial_ Other I Number of living units: n Number of bedrooms Character of soil to a dth of 3 feet: Water table depth SEPTIC TANK Type/Mfg Capacity No- Compartments PKG. TREATMENT PLT. ❑ Method of Disposal I �� 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 SEEPAGE PITS ❑ Depth x Size Number SUMPS ❑ Distance to nearest: + Well Foundation Property Line 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" 1 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 r certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall employ per subject to workman's compensa- tion laws of California." Th licant must call for all Irequ' ryinspections. Complete drawing on reverse side: ;J F Title: I�J�1 �M4� Date: Q` I `' Signed � } FOR DEPARTMENT USE ONLY ` Application Accepted by Date %—\0�O Area t Pit or Grout Inspecti Date Final Inspection by Date 1 Additional Comments: ❑ Stk 466-6181 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8355-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I IFEE NFO AMOUNT DUE AMOUNT-REMITTED CASH .` RECEIVED BY DATE �PERR/MITNOO, + EH13-2401EV.;/951 35, EH 14-26 . �r