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r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone 12091 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete-in Triplicate) i th District for a permit to construct and/or install the work herein described. This application is Application is hereby made to the San Joaquin Local Heal 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 1^ '+ `F V `�Ni City Lat Size PM Owner's Name Address�T Phone Contractor's Name License No. 7 Phone g- TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ � DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑•- - r DISTANCE To NEAREST: SEPTIC-TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE �. TYPC4 WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ IndustrialqI g {O Operi,Bottom ❑ Manteca Dia. of Well Excavation ! Dia. of Well Casing Ll Domestic/f?rivate 11 Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public 0 Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by t� Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material {Below 501 i TYPE OF SEPTIC WORK: NEW INSTALLATIONAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) t µms' N. Installation'will serve: Residence Commercial A—,-Other Number of living units: Number of bedrooms _ E — -- •.-t Water table depth Character of soil to a depth of 3 feet:'- SEPTIC TANK Type/Mfg Capacity I ry' No. Compartments PKG. TREATMENT PLT. E3 �y f, � . ' .:-. ... .. -: - �/ s Method of Disposal Distance to nearest: Well Foundation Property Line._ k- i � LEACHING LINE �IVo. & Length of lines { Total length/size FILTER BED ❑ Distance to nearest: Well Foundation"1 Property Line I A SEEPAGE PITS ❑ Depth Size ; Number f SUMPS ❑ �bista 'e to nearest: b Welt Foundation f Property Line DISPOSAL PONDS ❑. I I hereby certify that I have prepared this application and that the work will be done id accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. j Home owner;or licensed agent's signature certifies the.following: "I certify that in thefperfarmance of the work for which this permit is issued, I shall not 's compensation laws of California."Contractors hiring or sub contracting signature employ any person in such manner as to become subject to workman p rsons subject to workman's com ensa- ce s the following "I certify that in the performance of the work for which this per is issued, I shall employ pe j P tion IN Californ 4 1 4 4I The applican st call for II quired i specti . Complete drawing on -ever side, A. Signe Title: Date: EPARTMEN U$E ONLY " f l 8 Application accepted by Date Area C/CCL/ Pit or Grout Inspection by Date Final Inspection by Date 6 `� Y t 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 F FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE f ERMIT''NO. I INFO + EH 13-24(REV.10l83? EH 1426 s �