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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON 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 i Local Health Distrriict./ 7 SV ' Job Addres ct � City c"4, Lot Sit PM Owner's NameJ 16 Address ql ` �"'' v( a Phone c� r"k J . r Contrac r Address «"^'tr License No.3 ZV ZZ(° Phone `S � 4 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD- PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS s ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia- of Well Casing �. ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f M Public ❑ Other ❑ Delta Depth of Grout Seal _ Type of Grout I I I Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by _ I Repair Work Done ❑ Type of Pump H,P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Material (Below 51 i TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 QTAIR! DDITIONX, DESTRUCTION I 1 INo septic system permitted it public sewer is Y available within 200 feet.) Installation will serve: Residence Commercial&cher Number of living units: Number of drooms ! Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE No. & Length of linesTotal length/size X FILTER BED EJDistance to nearest: Weil SO Foundation 10 Property Line SEEPAGE PITS l I Depths . - Size -- -[�C-- Nymber SUMPSDistance to nearest: Well��(L` Foundation /d 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, an rules and regulations of the San Joaquin Local Health Diltrict. 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 signatur certifies the following: "I certify that in the performance of the work for which this permit is issued, l shall employ persons subject to workman's compens 3�_ tion laws of California." The applicant u call for I q 'ed inspections. Complete drawing on revrs s Signed Title: P Date: o FOR DEPARTMENT USE ONLY J Application Accepted by � Date ! 4-4— Area Z-7-3 Pit or Grout Inspection by Date Final Inspection b, Date l� ,. Additional Comments: E7 Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Heatth Permit/Services 1601 E. Hazelton Ave., P.O. .Bax 2009, Stk., CA 95201FEE - INFO AMOUNT DUE AMOUNT REMITTED CASH CK 11 RECEIVED BY DATE PERMI-I-NO. + EH 13-24(REV.1 i n sl I,q• 0 EH t4-26