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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1 {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.. J LJobZ(�� Lr Ci Lot Size f tr2�� PM Address Owner`s Na e Addr4 ess `� Phone �J Contract . '� Addressk 7 6 7 - - License No. ��L 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 - - - - - iii.�� p Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications El 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 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) ` Installation will serve, Residence Commercial. Other Number of living units: 4— Number of bedrooms l[ Character of soil to a de�pth9f'3 feet: Water table depth F SEPTIC TANK LIQ Type/Mfg P n i Capacity -a No. Compartments PKG. TREATMENT PLT. ❑ � �il Method of Disposal Distance to nearest: �iWell_1�11— Foundation I-('- Property Line LEACHING LINE ItNo. & Length of lines _-2 C r - -- Total length/size l� !D LLL FILTER BED ❑ Distance to nearest: Well Foundation_Z V/J_ Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ ;hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances,state Ill -...- 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 fallowing:"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 applicai must call f II re uired inspections. Complete drawing on reverse side. Signed Title:— Date: i FOR DEPARTMENT USE ONLY !� Application Accepted byeol Date r/ �— Are rr I Pit or Grout Inspection by Date Final Inspection by DateAfr �r '"� Additional Comments: .❑ Stk 466-6781 ❑ Lodi 363-3621 ❑ Manteca 823-7104 0 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# RECEIVED BY DATE PERMIT"NO. INFO CASH + EH 1324(REV.1/8E7 - EH 1426 Q '1 _ i