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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 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. Job Address Cit;/-MLot Size PM Owner's me Address - Phone I/* / Contr w/� 4)SrAddres� License N 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 WELT 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 1'1 Public 171 Other r Delta Depth of Grout Seal Type of Grout I I Irrigation _..Approx, Depth I 1 Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Weil Diameter Sealing Material Itop 50') �1 Depth filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ESTRUCTION I i INo septic system permitted if public sewer is available within 200 feet.), Installation will serve: Residence Commercial_ other '�t Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK,' J Type/Mfg Capacity `No. Compartments PKG. TREATMENT PLT. ❑ Get e Method of ispo�sal Distance to'nearest: Well �Dd Foundation A0 Property.Line s • r• :r LEACHING LINE `No. & Length off lines, I Total length/size FILTER BED ❑ Distance to nearest: .`r We'll,! f Foundation s j:Properly,Line �l SEEPAGE PITS ` i Depth Size, r Y Clef/ Number SUMPS 7 4 t Ll Distance to nearest: Well ' Foundation `` r"J Property Line DISPOSAL PONDS•.! ❑ I hereby certify that I have prepared this application and that the work wiEI be.done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. i � i 'Home owner or licensed a nt's signature certifies the following: "I certify,that'in the performance of the work for which this permit is issued, 1 shall not employ ahy-persdn in 77" manner as to become s ject to workman's-compensation law's of California."Contractor's hiring or sub-contracting signature certifies the following: ertif that in y the�erfo cg of the work t6r which this permit i§'issued, I shall employ persons subject to workman's compensa- tion laws of Calif o' r ``+ g '. f The a nt s all for all required ' ons C p t rowing on vever Sign d X Title' Date: I 'V9 PARTM NT USE ONLY Application Accepted by`' ' q Date t�i�1 1gr (� Area Pit or Grout!nspeciion by Date-\ Final Inspection by\QbMg. Date Additional Comments: I ❑ Stk 466-6781 ❑ Lodi 369-3621 V ❑ 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 INFO AMDUNT DUE AMOUNT REMITTED,_ ;'CASH'- RECEIVED BY, n DATE PERMIT"ND. * EH EH 14-2e;REV.tins] DO C*T�.