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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. i Job Address I �d +CLC�4ot Size Owner's Name AQ,_— Address _ Phone Contractor's Name LIZ -I— icense No. 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 WELL_ 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 ❑ Public ❑ Other ❑ Delta Depth of Grout Seal _ Type of Grout ❑ Irrigation —Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION EPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence L'Commercial__ ther Number of living units:I Number of bedrooms Character of soil to a depth of 3 feet: rpm, Water table depth SEPTIC TANK ❑ Type/Mfg C��,j v�-t� Capacity / 2L. No. Compartments a- PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line X1^1 LEACHING LINE Al o. & Length of lines T I (D C) Total length/size am FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 17--Depth __Size Co Number SUMPS ❑ Distance to nearest: Well Foundation_j 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 ce ies 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 I California." The plica t m call for alrequired ins tipns. om lete drawing on reverse si e. / Signed Title: Date: -7 J OR DEPARTMENT USE ONLY Application Accepted by ` Y klLl_ 1_1�_ Date Area Pit or Grout Inspection by 0/ Date 4 Final Ins ction by — Date e ' Additional Comments: — ❑ Stk 466-6781 ❑ Lodi 369 3621 ❑ Mp4iteca 823-7104 h Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK H RECEIVED BY DATE PERMIT"NO. INFO - + EH 13-24(REV.10/83) �� w EH 14-26 --