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APPLICATION FOR PERMIT SAPS JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 T 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 ��fl (� Job Address e 00 i ,I- . IYA_- 1,1 s City Lot Size \ko-9 PM Owner's Name 0 '�}`�` Address g o 7 „_ S� 1r .0 Phone r1 ° Contract 1L(14 C �� 1 Address 4 7� License No. 1 Z 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 11 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout 1 1 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') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence X Commercial _ Other Number of living units: Number of + dooms�- Character of soil to a depth of 3 feet: Water table depth C SEPTIC TANK YY Type/Mfg � u. LrLJ�i� Capacity J(L,0 C No. Compartments PKG. TREATMENT PLT. ❑ 1 Method of�Disposal, Distance to nearest: WellJrC� Foundation a Property Line � r � LEACHING LINE �K No. & Length of lines y Total length/size ( C k FILTER BED `❑ Distance to nearest: Well_�_ � Foundation Property Line SC" SEEPAGE PITS V9 Depth - Size 33? Number 3p SUMPS L] Distance to nearest: Well ( r Foundation to Property Line T5 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 must,, all for allr uir d inspections. Complete drawing on reverse side. 1 ' l (� Signed XML Title: Date: \9 sr—DIC V FO, DEPARTMENT USE ONLY�n Application Accepted by Date Area or Grout Inspection by ts� I Final Inspection by 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 RECEIVED BY DATE PERMIT NO. ,.EH 13-24(REV.rims)