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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone {209) 466-67$1 PERMIT EXPIRES TYEAR FROM DATE ISSUED lComplete 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. c Job Addres City Lot Size 47 Owner's Nama_ Address P .7�i`�'� Phone _ Contracto Address Rb_ -1 T4Ld_ qusr3 Olt, No.46, 3 �� Ph TYPE OF WELL/PUMP: DISTANCE TO NEAREST: INTENDED USE ❑ Industrial *omestic/Private I'1 Public I 1 Irrigation Repair Work Done ❑ Well Destruction ❑ PM =��tic NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION D PUMP. INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Gravel Pack _❑ Tracy _. TVpe -of Casing Specifications n Other rt Ll Delta Depth of Grout Seal Type of Grout _..Approx. Depth I I Eastern /Surface Seal Installed by - Type of Pump �.. H.P../�— State Work Done Well Diameters Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION I 1 DESTRUCTION I I Mo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence-- Commercial— Number ommercial—Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg PKG. TREATMENT PLT, EI +. Other Ti ' Water table depth _ Capacity '� No. Compartments Distance to nearest: Well Foundation LEACHING UNE ❑ No- & Length of lines FILTER BED ❑ Distance'to nearest: Method of Disposal Property Line Total Well Foundation Property Line SEEPAGE PITS I -i Depth Size Number n SUMPS L� Distance to nearest: Well Foundation Property Line S . DISPOSAL PONDS ❑ A. z 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. 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 shalt 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-musl call for alkequE(Ld,4wpeclions, Complete drawing on r ¢rse side. Signe Date: �- FQR DEPARTMENT USE ONLY�' O Application Accepted -by date Area 165 Pit or Grout Inspection by Date Final Inspection by Date f� Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369.3621 ❑ Manteca 823-7104 ❑ Tracy B35-6385 Applicant - Return all copies to: Environmental Health Permit/ Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 +. EH 1324 1 REV. EH 14-2e FEE INFO AMOUNT DUE AMOUNT REMITTED I CKO CASH RECEIVED BY DATE PERMIT NO. i