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APPLICATION FOR PERMIT I + SAN JOAQUIN LOCAL HEALTH DISTRICT 7 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES T 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 i made in compliance with San Joaquin County Ordinance No.548 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. y Job Address ! City Lot Size PM I Owner's Name dim Address _ Phone j Contractor ��r�[-` Address T c d.TM^~ - Als License Nqy-�� r ` phone, TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT F1DESTRUCTION ❑ r PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE r FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED US_E TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial i ❑ Open Bottom ❑ Domestic/Private ❑ Gravel Pack ❑ Manteca Dia. of Wel! Excavation Dia. of Well Casing i ❑ Tracy Type of Casing M ! O Specifications Public Other f� Delta Depth,of Grout Seal I I Irri ation ^•i - ' Type of Grout _ 3 g _..Approx. Depth ( I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H p - , } State Work Done Well Destruction L ❑ Well Diameter Sealing Material (top 50'1 i .Depth Filler Material (Below 501 St TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION i I (No septic system permitted if public sewer is Q(� available within 200 feet.) r-f Installation will serve: Residence lof�Commercia!_ Other V Number of living units: Number of bedrooms`_ Character of soil to a depth of 3 feet: 1 SEPTIC TANK '` �^ Water table depth ❑ Tyne/Mfg ` ` "�' Capacity , ,px!:C�44•4go. Compartments r PKG. TREATMENT PLT. ❑ s a•. Method of Disposal f -. Distance.to nearest: Well,N.,��Fpundation p- ! � Property r LEACHING LINE fJo. & Length of lines Total length/size �d FILTER BED r ❑ Distance to nearest:' Wdli Foundation .-c��—��Property Line k •� j SEEPAGE PITS ' I I Depth Number SUMPS r ❑' Distance to nearest: Welir,, 1 r 5 FoundationProperty Line i DISPOSAL PONDS 171 ,. + y.� I hereby certify that 1 have prepared this application and that,tlia work will-be done in accordance with San Joaquin county ordinances, state laws, and . rules and regulations of the San Joaquin Local Health Diltrict. Home owner or licensed agent's signature certifies the following: "1 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-w. tion laws of California." The applicant must call for re red ins 1 q pec ions. Complete drawing on reverse side. Signed X - .%' Title: - Date: FOR DEPARTMENT USE ONLY Application Accepted by Data 4 Area / Pit or Grout inspection by Date Final Inspection by Additional Comments: - ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 635-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.' CA 95201 M 1 INFO -�-_.- AMOUNT REMITTED. RECEIVED 8Y FEE AMOUNT DUE CK 1 CASH 1 DATE- PERMI7'N0. +.EH 13.24-1 REV.v H51 -- - "-^7Q n .-• _ -: -. ,� it