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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON.AVE., 8TOCKTON, CA Telephone (209) 466-6781 1 t PERMIT EXPIR159'I'YEAR FROM DATE ISSUED 4 (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. n Lot Size_ '�`� PM Job AddressW2 s 2 City ��—/ (/FJ F✓ V/f � 7 Phone yU I)_7� ,� Owner's Name tolzrd Address 'r ". ,[ yContractor ress � Y a-' License No� .; -3` yr Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ! PUMP INSTALLATION-%0 SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 1 f INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS l C] Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing I ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'1 Public f] Other C1 Delta Depth of Grout Seal Type of Grout I I Irrigation _.Approx. Depth i I Eastern Surface Seal Installed by 1 Repair Work Done ❑ Type of Pump H.P. State Work Done — ', Well Oestruction ❑ Well Diameter Sealing Material atop 501 Depth I Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION l r REPAIR/ADDITION i I DESTRUCTION ( 1 (No septic system permitted if public sewer is, available within 200 feet.) Installation will serve: Residence=a' Commercial_ Other Number of living units: Number of bedrooms .-3 Character of soil to a depth of 3 feetx ` Water table depth ' SEPTIC TANK ❑ Type/Mfg ` CapacityLNo. Compartments t PKG. TREATMENT PLT. ❑ Method of Di!pual I ` ! Distance to nearest: Well_ 0.-..7' Foundation A) - Property Line LEACHING LINE ❑ No. & Length of lines Z Total length FILTER BED ❑ Distance to nearest: Well L7 Foundation — Property Line- r SEEPAGE PITS I I Deprh w Size Number f" SUMPS L� Distance to nearest: Well Foundation C) 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 lawst 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 fof�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 st call for all r uired ins ctions. Complete drawing on reverse side. ` Signed X Title: Date: ' C ' R D ARTMENT USE ONLY I Application Accepted by ~� Date _��. _ Area L..r._ j Pi or Grout Inspection by _ ate .� Final Inspection by Date �� Additional Comments: 0 Slk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 820164' ❑ 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 OUNT DUE AMOUNT REMITTED CK RECEIUED'DY DATE PERMIT NO. , INFO CASK 1.. + EH 13-24 tREV.t r n 51 '�f,J ' ( /! j ` E EH 14-29 U s E.