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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i (Complete in Triplicate) I i 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. Job Address ` City Lot Size PM & '.-/ .Owner's Name- v Address 13S 3 D Contract *_ 33 Address �. �_ � / 6 !�,�& 'License No. z z(P Phone ( +� -r� ST TYPE OF WELL/PUMP: =y 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 1� I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS } . i ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications . l F1 Public Other Fl Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth l I Eastern Surface Seal installed by - Repair Work Done ❑ Type of Pump H.P, State Work Done_ Well Destruction [I Well Diameter Sealing Material (top 50') - Depth Filler Material I Below 50') 'f TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR ADDITION I DESTRUCTION i I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_✓ Commercial— Other Number of living units: Number of belooms F/ice Character of soil to a depth of 3 feet: - Water table depth SEPTIC TANK ❑ Type/Mfg - f Capacity No. Compartments" PKG. TREATMENT PLT. ❑ x� Method of,Disposal .Distance to.nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line J _ SEEPAGE PITS I I Depthh ..Size C2.._x Number SUMPS Distance to nearest-:"' ,Well Z,050 �Foundation Property Line 67 i DISPOSAL PONDS ❑ hereby certify that I have prepared this application and thai'the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health Distridt. 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 subcontracting 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 it call for al r uir inspections. Complete drawing on reverse Sid Signed Title: FOR DEPARTMENT USE ONLY ` -Application Accepted by Date Z pr7��4 r Area' Pit or Grout Inspection by 1 - Date y Final inspection by Date l7 - Addiiiorial Comments: ❑ 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 8Y DATE PERMITNO. INFO CASH + EH 13-24(REV. /KS) EH 14-2a 4V�*