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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. i, ll)) Job Address Cit Lot Size PM y 4� Owner's NameL.�jj `� Address � Phone levt r z 7� P Z Phone Contras r Address icense No. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ t PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 1J �r DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ' FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 1. INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation - Dia. of Well Casing ❑ Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing ' Specifications I FI Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout----- I rout ___I Irrigation --Approx. Depth I I 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 (Below 501 I TYPE OF SEPTIC WORK: NEW INSTALLATION IREPAIR/ADDITION l I DESTRUCTION l 1 (No septic system permitted if public sewer is available within 200 feet.) _ Installation will serve: Re idence-< m�Comeiciai Other ' (� ..s.• �..�.r--- ��w�..� - s=a-.:,. 'Y � --. - •_;r - ter:,...-.—T-,� _ k Number-of living units:--l T Number of b rooms - ----�--• - -�.. -,ti: Y ~!� t Water table depth ~' Character of soil to a depth of 3 feet: �" P , SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ i Method of Disposal Distance to nearest: Well I Foundation Property Line LEACHING LINE No. & Length of lines Toyl length/size 6, � FILTER BED L-] Distanceto nearest: Well t0 Foundation M Property Line _ SEEPAGE PITS 1 I Depth Size Number SUMPS Ll Distance to nearest: Well f Foundation Property Line DISPOSAL PONDS Cl d i I hereby certify that I have prepared this application and that the-iwork will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the Sart Joaquin Local Health Diarist. I Home owner or licensed agent's signature certifies the following: "ticertify that iri the peitormance 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." b i The applicant must a or all re uir in ciions- Complete drawing on reverse e. Signed X Title: sidI Date: FOR DEPARTMENT USE ONLY Application Accepted by Date �,� Area Pit or Grout inspection by Date % `Final Inspection by� ��L Qat -t Additional Comments: ❑ Stk 466-6781 ❑ Lodi :x369-3621 - EI-Manteca 823-7104 "❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Sarvices`1601`E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 P 1 { FEE AM UNT DUE AMOUNT REMITTEDCASA RECEIVED BY DATE PERMIT'NO. ✓_ INFO +.EH13-24iREV.t/1t 5) �•(�� `I� k r /`I> EH 1426 '�" .