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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE E 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 andlor 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. 7 (0 Jab Address Q f Cit Lot Size r Owner's Name / Address Phone Address CIL License No3BS?--/ Phone,76Ui Contractor �y TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER-© -- -- -- DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE t FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i 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 ❑ Other Cl Delta Depth of Grout Seal a Type of Grout -- i 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 50'1 Depth Filler Material (Below 50') — TYPE OF SEPTIC WORK: NEWINSTALLATIONrT REPAIRIADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ �?ther Y r' Number of living units: Number of drop Character of soil to a depth of 3 feet: / Water table depth SEPTIC TANK ❑ Type/Mfg Capacity-js�s No. Compartments 2 PKG. TREATMENT PLT. ❑ r( Method of Disposal Distance to nearest: Well ®� I Foundation 9;2-5' Property Line f 1 LEACHING LINEFr'No. & Length of line Total length/size .1a FILTER BED ❑ Distance to nearest: Well 120 t Foundation Property Line�, SEEPAGE PITS i i�Depth Size 'Co�- c ...��Number 3 IF SUMPS Ll Distance to nearest: Well 7 3 .Z....-_ Foundation _ Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state lJandrules 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, Iemploy any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting 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 ction laws of California." The applicant must call for a required inspections. Complete drawing on reverse side. Signed X/! Title: (L Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area i CP ' r Grout Inspection by Date Final Inspection by ate Additional Comments: ElStk 466-6781 ElLodi 369-3621 ❑ Monte 623-7104 L1 Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permi0l;ervicas 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO _ _ CASH ♦.EH13-24(REV.I/H 5) 7b EH 14-26 L -