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t APPLICATION FOR PERMIT iN JOAQUIN LOCAL HEALTH DISTRtt-T S t-d 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES'1 YE AR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the Sarr Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is I " 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 of Size Y P _ Owner's Nary _ Address Phone Contractor ress �6nse No Phony TYPE OF WELL/PU P: NEW ELL D WELL REPLACEMENT ❑ DESTALtCTION ❑ PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER ❑ s DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS - INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n 1-1 Industrial ID Open Bottom C1 Manteca Dia. of Well Excavation Dia, of Well Casing ❑ Domestic/Private ❑ Gravel Pack y❑ Tracy Type of Casing Specifications Cl Public 171 Other 171 Delta Depth of Grout Seal 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 ❑ Weil Diameter baling Material (top 501 Depth Filler eria! (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I ]R;EPAIRIDDITIO'N 1.1 DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacit d No. Compartments PKG. TREATMENT PLT. ❑ y� Method of DisRosal Distance to nearest: Well/© Foundation Property Line Z9 LEACHING LINE ❑ No. & Length of lines 1 Total length/size FILTER BED Distance to nearest: Wel Foundation J Property Line SEEPAGE PITS I I Depth Size Number . SUMPS ❑ Distance to nearest: Well 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 laws, and rules and regulations of the San Joaquin 0 qu n 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 F employ any person in such manner its 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." I The applicant u cal r a fired inspecti S. mplete drawing on reverse side. f + Signed Title: Date: x/ A? FOR DEPARTMENT USE ONLY Application Accepted by Fkc rt Date �- 13-rS Area . Pit or Grout Inspection by Date Fina! Inspection by Date t Additional Comments: q ❑ Stk 466-6781 ❑ Lodi 3M-3621V ❑ Manteca 823-7104 ❑ Tracy 83 -fi385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE j INFO AMOUNT DUE - AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT-NO, j +.EH13-24(REV-rix5) -70 - t3)g� Pl_ 139 EH 14-26 1