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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTO14, CA Telephone (209) 466-6781, .. PERMIT EXPIRES 1 YEAR FROM DATE ISSUED s (Complete in,Triplicate) + Application is he!eby 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 i Local Health District: � r Job Address gz>, li 2 �� iC� _ Cit /g�T/% Y Lot Size PM Owner's Name Address 2 Phone Contractor Address J?o� License No. , d Phone 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 ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack C1 Tracy Type of Casing Specifications ❑'Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ---_] ❑ Irrigation —Approx. Depth ❑ Eastern Surface Seal Installed by 1 Repair Work'Done L Type of Pump H.P. State Work Done Well Destruction ❑ Well.;Diameter Sealing Material (top 501 Depth Filler Material (Below W') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is 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: Water table depth ` SEPTIC TANK 1 Type/Mfg YCapaciryot�ad::6 No. Compartments PKG. TREATMENT PUT.:❑ v �: fi. Method of Disposal Distance to nearest: Well�r Foundation Property Line 'r' LEACHING LINE _' � No. & LengtHjo`i'lines �_ . '=� Total length/size FILTER BED ❑ Distance to nearest: Well '. F�Foundation ��lff Property Line SEEPAGE PITS ❑ Depth Size } # Number F I ` SUMPS is ❑ Distance to nearest: —Well Foundation Property Line ` DISPOSAL PONDS ❑ k .' I here4 certify that I have prepared this application ancljth,at 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 agents signature certifies tle following: "Icrpertify that in the performance of the work for which this permit is issued, !shall not employ any person in such manner as to become subject,to workinan'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.AAklich this permit is issued, I shall employ persons subject to workman's cc 'onsa tion laws of California:" ` 4 M.,. ::i The applicant must call for re' inspe Vons. Complete drawing on reverse side. pr . Signed X I Title Date: I l } FOR DEPARTMENT USE ONLY ' Application licceptedy – Date �� Area W Pit or Grout Inspection by Date iI + Final Inspection b Y Date Additional Comments: ❑ Stk 466-6781 ^❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 1 Applicant- Return all copies to:YEnvironmental Health Permit/Services 1601`E:,Hazelton Ave., P.O. Box 2009, Stk., CA 95201 F ""AMOUWT'DUE A-M0UNT- EMITE '_ ' -CK RCVED BYf ' DATEINFO CASH PERMIT'NO. T + EH 13-24 f REv.-t;x 51 r - "."'�""'.�'y"'�."�"'" 7