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APPLICATION FOR PERMIT - SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone.(209) 466-Ml + 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 well/pump and the Rules and Regulations of the San Joaquin i Local Health District. 4 lkloJ '�G Job Address _ � � � 6�� - City OwLot Size PM�} Owner's Name - Address T Phone z '" Contractor 6 Q Address 5 YD T License No. 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 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I [I Industrial 11Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ( ❑ Domestic/Private ❑ Gravel Pack L1 Tracy Type of Casing Specifications Ll Public E] Other 1-1DeltaDepth of Grout Seal Type of Grout ❑ Irrigation �pprox. 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 r Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1] REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septiclable s in m permitted if public sewer is avaInstallation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth IS SEPTIC TANK Type/Mfg i � Capacity_— No. Compartments PKG. TREATMENT PLT. ❑ -max R ?"f Method of Disposal i Distance to nearest: Well t Foundation Property Line I h LEACHING LINE ❑ No. & Length of lines Total length/size FILTER HED ❑ Distance to nearest: Well Foundation Property Line 1 _ k SEEPAGE PITS ❑ Depth Size Number SUMPS C1 Distance to nearest: Well r Foundation - Property Line DISPOSAL PONDS ❑ I 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. g 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'Cal'rfomia." Contractors hiring or subcontracting signature certifies 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- tion laws of California." The applica must call for all required inspections. Complete drawing on reverse side. Title: IPSP J'�Z�� — Date: I r I, FOR DEPARTMENT USE ONLY sc`r * ' Date Area I Application Accepted by ; b A_Pit or Grout Inspection Date "-' ` Final Inspection by Date Additional Comments: t [I Stk 466-6781 El Lodi 369-3621 C3 Manteca 823-7104 ❑ Tracy $35 635 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTEDIL OCK RECEIVED BYE DATE PERMIT'N0. INFO �ji ' + EH 13-24(REV.I/8 51 ��' "7� EH 1446 - - -