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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 TYEAR 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. 1 ' t�� Job Addre g� ` J� C4 Lot Size �� PM .. ► ��W�`fl ��'�` c Owner's Name 1"r Addres # Contractor �<� 'Addre z ILL. Lic se No. Phon TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ s 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 ❑ Industrial t ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Pat Specifications ❑ Domeslic/Private ❑ Gravel Pack ❑ Tracy '� Type of Casing P F] Public F= Other ❑ Delta Depth of Grout Seal Type of Grout �. I I Irrigation —.Approx. p Depth l I Eastern Surface Seal Installed by r Repair Work Done O Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Deptht Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION . DESTRUCTION l I (No septic system permitted it public sewer is . e� f available within 200 feet.) +`s Installation will serve: Residence 7X Commercial_ Oth r Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: L� -� ��1^-77��--��- Water table depth SEPTIC TANK ❑ Type/Mfg` Capacity— No. Compartments PKG. TREATMENT PLT. E3s'- Method of Disposal u Distance#to nearest:} ;� Well Foundation Property.Line LEACHING LINE No. & Length of lines Total length/size 7 .. L !7 FILTER BED � 4 EIDistancei5 to nearest:, Well Foundation Property Line 14 r SEEPAGE PITS .Depth -!752 Size Number SUMPS L1 Distance to nearest:' Well Foundation Property Line I DISPOSAL PONDS ❑ 1 1 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. P) .,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,-1 siiall-not"-"" 'I employ any person in such manner as to become s6biect to workman's compensation laws of California." Contractor's hiring or sub-contracting signature fcertifies the following: "I certify that in the peEfaEmance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California.". _. 011r i The applicant s fos.all req uir in pecti s. Corriplele awing on arse side. # 4 Signed j Title f ' Date: --25 NJ U FOR DEPARTME USE ONLY ^ Application Accepted by ' ' Date Area - z.- � s il Pit or Grout Inspection by Data Final Inspection by ...—o �Date V 4 r r Additional 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 CASH RECEIVED BY DATE PERMIT'NO. I t.EH 13-241REV.t/Hb1 INFO h EN 14-26