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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA 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 C Local Health District. .fob 16dress PM ze: Tom-- II � 0 )t`�1 ss �` � � Phone 2- � — �- .. Owner's Name Contractor's Name License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 " PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE-TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD- PROP. LINE T FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C p Industrial ElOpen Bottom ElManteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing—, Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout El Surface Seal Installed by C1 Irrigation --Approx. Depth Repair Work Done ❑ Type of Pump H,P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 'Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is t available within 200 feet.l Installation will serve: Residence_ Commercial— Other ,// Number of bedrooms "" - -- < ll t Number of living units: � I epth Character of soil to a depth of 3 feet: Waterytatile,'- SEPTIC TANK Type/Mfg - Capacity-— © _ No. Compartments Method of`Dyspa PKG. TREATMENT PLT. ❑ J Distance to nearest: Welly— Foundation Property Line LEACHING LINE .No. & Length of lines T�tai length/sizes 0, L FILTER BED r ,Q aDistance to nearest: Well {Foundation! ly Property Line ./SEEPAGE PITS . Depth Size Number E SUMPS , IV El Distance to nearest: Well 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 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."Contracto`r'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 applic st c it for II required inspections. Complete drawing on r sidee� Signed Date: Title: ►�,®^ _i "< D FOR DEP TMENT USE ONLY �J, II �? ion Accepted b Date/ V Area --? Applicat p y I Pit or Grout Inspection by Date Final Inspection'by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7144 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,iStk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK# I RECEIVED 9Y f]ATE PERMIT NO. INFO r� 1 +EH 13-24(REV.10133) EH 14-28 I