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III $? APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT. 1601 E. HAZELTON AVE., STOCKTON, CA tiY 3 3 Telephone (209) 466-6781 (� d Lit- PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r (Complete in Triplicate) C l K � C✓ti��J is heieb made to the San Joaquin local Health District for a permit to construct and/or install the work herein described. This application is ApplicationY made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for welVpump and the Rules and Regulations of the San Joaquin l Local Health District. City �OCkl0l Lot Size_ rX $`�r PM Job Address J �9 + , p� �J s J �(}� /yM Owner's Name Address "DS Phone kContractor Address _ _ License No._ Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION El SYSTEM REPAIR LJ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES., DISPOSAL FLO. PROP. LINE 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 ElGravel Pack 11Tracy Type of Casing Specifications \n I public 1-1 Other t f 1 Delta Depth of Grout Seal Type of Grout `1Y 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 ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE. OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION (Nailsepticable systithinem permitted if public sewer is ( 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 k SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ YMethod of Disposal Distance to nearest: Well Foundation Property Line ,i LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest. Well Foundation Property Line d SEEPAGE PITS l ) Depth Size Number SUMPS Cl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ j rules certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and f rules and regulations of the San Joaquin Local Health District. 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."Contractors hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject 10 workman's compensa- tion laws of California." The applican must call fo all requi inspections. Complete drawing on reverse side. p� Signed X Ti ph _ Date: 3 FOR DEPARTMENT USE ONLY r rl Application Accepted by Date 3- 1 ,kk — Area V Pit or Grout Inspection Date Final Inspection by Date 4 a Additional Comments: 02 ❑ Stk 466-6781 ❑ Lodi -3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E..Hazalton Ave., P.D. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. INFO + EH 1321(REV.i i H 5) EH 11-28 f ,