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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA I Telephone (209) 466-6781 PER-MIT 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. 5519 for sewage or No. 1862 for wail/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address �L�(�—�1..�5r_.� City Lot SizeX - S� PM Owner's Name Address4is PhoneqSi— Cantractor , Address f7 License No. PhoneA - TYPE OF WELL/PUMP: NEW WELL C WELL REPLA MENT ❑ DESTRUCTION ❑ PUMP INSTALLATION C SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ___ DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications [I Public ❑ Other n Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth I Eastern Surface Seal Installed by - Repair Work Done .3 Type of Pump H.P. _ State Work Done Well Destruction ❑ Weil Diameter Sealing Material Itop 50'1 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION . I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Type/Mfg 7""'� L_ �yj� , Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line { LEACHING LINE ❑ No. & Length of tines Total Length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS Depth Siza Number C SUMPS 0 Distance to nearest: WellS� Foundation 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 f 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 Ca ornia." The apptica st call for I q , Zspections. Complete drawing o everso side. Signed Title:' Date: v FORMPARTMENT USE ONLY Application Accepted by yq Date — A Pit or Grout Inspection by Date Final Inspection Dat Additional Comments: s ❑ Silk 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 95201FEE i INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED By DATE �/7PyEr - RMIT''NO. 5—/— (C/ 1I /0,3 EH 14-29 r 7 � I