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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1641 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in TI•iplicate) 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 Address - _ Phone Contractor -� r Address License No. 7. Phone 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 f FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public i ❑ Other ' ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation —Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material(Below 50') - TYPE OF SEPTIC WORK: NEW INSTALLATION, REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is f available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms / Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK g Type/Mfg ,:,eV4 Capacity No. Compartments PKG. TREATMENT PLT. ❑ / Method of Disposal D ' �Distance,to nearest: Well �d Foundation Property Line,.�_�-�_ i LEACHING LINE "No. & Length of lines 2 Total length/size Q FILTER BED F] Distance to nearest: Well Foundation Property Line S ,. SEEPAGE PITS ❑l DepthSize Nrmber SUMPS Distance to nearest: Well Foundation 1/940 Property Line DISPOSAL-PONDS ❑ i hereby certify that I have prepared this application and thatthe work will be done in'accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local HealthoDistrict. r 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 shall not employ any person in such manner as to become subject to workman s c6nIloansation.laws.of..Califomia." Contractors hiring or sub-contracting signature cef ifies 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- tiori laws of California." i, The applicant must call for ailrequiredihspections.:Complete drawing on reverse side,'- u; Signed X y1� r ik"4l�- = _T'RIe: 'W ` �f' Date I3 a FORIDE PARTMENT.USE ONLY, .� Application Accepted bye " AI- x Date Area Pit or Grout Inspection by `"5 `' Date"r`" "Final Inspection by��FDate o - R1,. f Additional Comments: ❑ Stk 466-6781 �. . C7 Lodi<f369-3621 ❑ Manteca 823-7104 -p Tracy $3b-6386 } Applicant,- Return all.copies to: Environmental H,al6"Permit/Servicea 1601 E. Hazelton Ave., P.O. Box 2008, Stk., CA 95201 FEEi.-"1Nf0 -V AMOUNT DUE. AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT NO. +- K ♦ EH13-24(REV.i/85l EH 142E