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APPLICATION FOR P RMIT SAN JOAQUIN LOCAL. HEALTH DISTRICT 1601 E. HAZE i 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 1. made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for weld/pump and the Rules and Regulations of the San Joaquin Local Health District. City Fa� -1 Lot Size A2 .. PM Job Address i ' "`U Address _ T Phone. Owners Name Address Contractor) � /�[7 License No, Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP IN ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC-TANK SEWER I-INES 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 Type of Casing Specifications ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy. Type of Grout (I Public ❑ Other Q Delta Depth of Grout Seal Yp } I I Irrigation —.Approx. Depth l I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State Work Done 4 Well Destruction ❑ Well Diameter• Sealing Material atop 50'1 r Depth Filler Material IBelow 50') I TYPE OF SEPTIC WORK: NEW INSTALLATION �,{ REPAIRIADDITION I 1 DESTRUCTION I 1 (No septic system permitted if public sewer is f available within 200 feet.) Installation will serve: Residence-A!," Commercial Other "' Number of living units: .. Number of bedrooms b '3 Character of soil to a depth of 3 feet: _ .— 1 , �� Water table depth SEPTIC TANK TYPelMfg Capacity Z2g„f — No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal v Distance to nearest: Well ` 7 Foundation '!�� Pr-operty Line: �"� w - we. -'G LEACHING LINE t� No. 8 Length of lines ��--- Total len tg�h/§lie FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS Depth J� 7' Sire _ Number i y Foundation .T�'.. Property Line - rr a SUMPS L Distance to nearest: Well ___ 'J 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, stare laws, and r rules and regulations of the San Joaquin Local Health District. Y;- Home owner or licensed agent's signature certifies the following: "I certify'uthai.in'irie performance of lite work,,for which this permit is issued, I shall not employ any person in such manner as to becomesubject-to-workman's compensation laws of California.” Contractor's hiring or sub-contracting signature } certifies the following: '9 certify that in the performance of the work for which this permiYis"itsuea';°l shall employ persons subject to workman's compensa tion laws of California." The applicant must call fpr all re wired inspections.,Carripleta_d'rawing on reverse side. e Signed X .Title: -p Date: r FOR DEPARTMENT USE ONLY 23 Application Accepted by .� Date Area - ' Pit or Gout Inspection by T . Y'- Date Final Inspection by `✓ >'C� f Date r Additional Comments: ❑ Silk 466-6781 El 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 2099, Stk., CA 95201 1 k FEE AMOUNT DUE AMOUNT REMITTED CASH -. REgF VED.BY r,. ATE,_,,.,. -_ ,PERMvI7'N0._ w.. .„.._b.� .INFO. y -_ -�' � - _ EH 14-28