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--�IPPLICATIOIV—FOR PERMIT COP �- - 4 SAN JOAQUIN LOCAL HEALTH DISTRICT f 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781- PERMIT EXPIRES TYEAR 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 City_ e ��Lot Size_ �a PM Owner's Name e �r✓�yr�d Address �� Phone 4. . Contractor Address License No 1!S 5 a o_�_ Phone?90' TYPE OF.WELL/PUMP: -.NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ' PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ r n 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Q Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F] Public n Other ❑ Delta Depth of Grout Seal Type of,Grout I 1 Irrigation -Approx. Depth l 1 Eastern Surface Seal Installed by Repair Work Dane ❑ Type of Pump H-P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material )Below TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION DESTRUCTION l i 1No septic system permitted if public sewer is �j available within 200 teet.1• __,. Installation will'serve: Residence Commercial_ Ojher /(�.� Number of living units: Number of beds Character of soil to a depth of 3 feet: �0� Water table depth ,SEPTIC TANK Cf Type/Mfg —' '-CapacitV No. Compartments A PKG, TREATMENT PLT, 0 1 i Method=of Disposal EL Distance to nearest: Well Foundation Property Line I nO--- LEACHING LINE ❑ No. & Length of lines � Total,length/size FILTER BED Distance to nearest: Well�_y.- ., Foundation. Property Line a SEEPAGE PITS C 1 Depth Size .. , Number SUMPS D Distance to nearest: Well Foundation Property Line :DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work wil[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 workmen's compensation laws of California." Contractors 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." j The applicant must all for all r fired ' spact. ns. Complete drawing on reverse side. t Signed X Title: --Aae-v1+ Date: f DEPARTMENT.USE ONLY I �. Application Accepted by Date Area I Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 I Applicant - Return all copies to::Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 \\ I FEE AMOUNT DUE AMOUNT REMITTED CK 11RECEIVED BY GATE PERMIT NO. INFO CASH EH 13-24(REV.r/85) EH 11-20 l/VV