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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA I Telephone (209) 466-6781 PERMIT 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.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. a Job Address City Lot Size PM Owner's Name 4 t/ Address Phone Contractor FcULGe— _Address 1�;8� �/ H�%rl�rGJL.ice License —.�iSs� Phone Te TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ %01 OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP" LINE 1 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 )' ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing -r Specifications �. f'l Public F Other f:-1 Delta Depth of Grout Seal Type of Grout I I I Irrigation .Approx- Depth I 1 Eastern Surface Seal installed by # Repair Work Done ❑ Type of Pump H.P. State Work Done_ S Well Destruction ❑ WWell Diameter Sealing Material (top 50') c Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I 1 INo septic system permitted if public sewer is (rl } available within 200 fe:et.I ` Installation will serve: ResidenceJ__ Commercial—_.Other- Number of living'units _L�__ Number of bedrooms Character of soil to a depth of 3 feet: Dd P�� "'''""" "" ,Water-table de•'pfh• �j 1 k SEPTIC TANK '❑ ,Jype/Mfg\. Capacity, yrs No. Compartments1. . �1 PKG. TREATMENT PLT. 17 F_, Method of Disposal Distance to nearest: Well /00 Foundation /0 2 Property Line i LEACHING LINE 'V(`No.�&Length of lines /7/`A:�W `T Total length/size FILTER BED 1'S 4 ❑ Distance to nearest: Well/64 '0�7T Foundation A0 I T Property Line �r3 SEEPAGE PITS 11 1 Depth Size Number SUMPS - 0Distance to nearest: Well Foundation Property Line DISPOSAL PONDS f 0 J' : I hereby certify that I have prepared'ihis application and that the work will be done in accordance with San Joaquin county ordinances!state laws, and rules and regulations of the San Joaquin Local Health DiMrict. , 3 i 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;'9 certify that in the performance of the work for which-this permit is issued, 1 shall employ persons subject to workman's compensa- tion laws of California.-, r ,r,�-„--..-�-.:�-....�;.....STT -•�, The applicant must call for 11 required inspections. Complete drawing on reverse side. Signed X �` 1 �� Title: Date: A:> l O OR DEPARTMENT USE ONLY G Application Accepted.by Date 0.4 Area 2 l 6 I Pit or Grout Inspection by Date Final Inspection by Date 16 �2- 3 t Additional Comments: t ❑ 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 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT 1V0. INFO CASH + F �.EH 13-24IREV.1/x5) �O ,U (� EH 14-26