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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE I ON AVE., STOCKTON, CA Telephone 12091 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 welt/pump and the Rules and Regulations of the San Joaquin k Local Health District, r.•-n O !�/sla F Job Addr City � of Siza PM I 1 ^ Owner' m ' . { 12-Address - - Phone .f Contr C1" Addres ' _ _ _ _ �icense_Nol � Phone .. ^TYPE OF WELL/PUMP: NEW WELL ❑ ,,,,, ,,WELL REPLACEMENT L1N DESTRUCTION ❑ i PUMP INSTALLATION �lYSYSTEM REPAIR Cl-. OTHER ❑ . k • r DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES- _ f .DISPOSAL_F_LD. PflOP_.11NE_ - ---\- -�7— FOUNDATION V AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ElOpen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing �� (,Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications C] Public ❑ Type❑ Delta Depth of Grout Seal of Grout E3 Irrigation ---Approx. D ❑ Easternurface Seal Installed by Repair Work Dane LlType of Pump H.P. -�' - State Work Done 4 , i Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50.1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is I available within 200 feet.) I Installation will serve: Residence Commercial_ _ Other # Number of living units: Number of bedrooms e } Character of soil to a depth of 3 feet: Water table depth � Capacity No. Compartments SEPTIC TANK ❑ Type/Mfg I PKG. TREATMENT PLT. ❑ l� Method of,Disposal �{- t Distance to nearest: Well#k.r Foundation Property Line R f *'LEACHING LINE ❑ No. & Length of lines Total length/size { rFILTER BED ❑ Distance to nearest: Well !" � Foundation Property Line r SEEPAGE PITS ❑ Dept,A`,-1. Size _ ( Number /DISPOSAL ❑ •Distance-to-nearesc--a:--•W �--�-- Well ---Property-Line 4 f DISPOSAL PONDS ❑ � r hereby certify that I have prepared this application and that the work will be done in accordancd.with San Joaquin county ordinances, state laws, and rules and regulations of the San-Joaquin-Local Health-District:»• -^ Homeowner 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 i employ any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature z certifies the foil Ing: "I certify that in the performance 6f the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of li ornia." tThe applic t st call for all required ins s. Co a drawing rse side. r Signed Title: �� .r i Date:, l t 1 FOR DEPARTMENT USE ONLY ,-,l Date 7 r Area r - Application Accepted by tDate Final Inspection by Date � Pit or Grout Inspection by Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 83556385 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 BY DATE PERMIT"NO, INFO CASH 1 + EH 13-24(REV.1/6 5) �� / EH 14-28