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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA No iNtlL /0'."1£Y' � "Telephone {209) 466-6781 PERMIT EXPIRES'1 YEAR FROM DATE ISSUEDM"'' ' {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.' ff �7 fM ' - ..} �., �'. ,f ,Lot Size(Go2 f "`��0 PM Job Address - -- Cit Owner's Na Address Phone 'Contractor F Address License No. Phone v TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION El . PUMP INSTALLATION 11 SYSTEM REPAIR El OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. 01 FOUNDATION AGRICULTURE WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREAUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ a Dia. of Well Excavation -Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F ❑ Public ❑ Ot ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work ❑ Type of Pump H.P. State Work Done We truction ❑ Well Diameter Sealing Material Itop 501 Depth- Filler Material (Below 50'i - - TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRlADDITION ❑ DESTRUCTION X (No septic system permitted if public sewer is 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 _ ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ s Method of Disposal Distance to nearest: Well Foundation Property Line +� LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED t ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS _ ❑ Depth -tt- Size Number i 4 SUMPS O.. Distance to nearest: Well Foundation Property Line f k DISPOSAL PONDS ❑ 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. } 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 compensation laws of California."Contractor's hiring or-sub-contracting signature certifies the following: "I certify that in the performance of the work for which.this permit is issued,'l shall employ persons subject to workman's compensa- tion laws of California." `r The applicant must call for all required ins ctions. C mplete drawing on reverse side. (Si Title: Date: FORPARTMENT USE ONLY f ~ Date 3 t3 Area v Application Accepted by r Pit or Grout Inspection b Date Final Inspection by t Date . . Additional Comments: ' , ! ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Mantec -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 I AMOUNT REMITTED C SH -RECEIVED BY DATE PERMIT NO. h INFO k +EH13-24(f16V.5/95) 00 i>2>q� w EH 1426