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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA < Telephone (209) 466-6781 v\ 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/pu p and the Rules and Regulations of the San Joaquin Local Health District. Job Address City Lot Size S, M Owner's Name Address Phone Y - ?� Contractor Address C License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SE ER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGR ULTURE WEEL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AR ONSTRUCTION SPECIFICATIONS ❑ Industrial El Open Bottom ❑.Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'1 Public n Other F1 Delt ,Depth of Grout Seal Type of Grout I I Irrigation --Approx. Depth l I stern ►Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. 1 State Work Done_ .S Well Destruction El Well Diameter Sealing Material Itop 501 Depth 3r IFiller Material (Below 501 ` TYPE OF SEPTIC WORK:' NEW INSTALLATION REPAIR/ADDITION I I� D�STRJ1,0N I I (No septic system permitted if public sewer is �/ f t{L?///la avails with' 2 feet.) Installation will serve: Residence_ Commercialther � � �� 1 Number of living units: Number of bedrooms(2yt' �J t: Character of soil to a depth of 3 feet: � Water table depth SEPTIC TANK ElType/MfgK-10-1Capacity l d y No. Compartments PKG. TREATMENT PLT. ❑ `� Method of Disposa Distance to nearest: Well foundation Property Line LEACHING LINE ❑ No. & Length of lines To IIllength/size IV FILTER BED ❑ Distance to nearest: Well Foundation� 5 '1� Property Line SEEPAGE PITS I I Depth Size _ Nu er SUMPS Cl Distance to nearest: Well 7�tA— Foundation 9. 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 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 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." The applicant st call for al squired inspections. Complete drawing on reverse side. Signed X Title: Qi(itI'-�YI ,,L'(� Date: 7 QFOR DEPARTMENT USE ONLY Q To I\AApplication Accepted by `\ Date V Area Pit or Grout Inspection b Date Final Inspection by Date/ " Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 AMOUNT DUE AMOUNT REMITTED CASH CK 4 RECEIVED BY /r DATE PERMIT NO. + EH 13-24(REV.I/N5) EH 14-26