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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ` 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 l PERMIT EXPIRES 1 YEAR FROM DATE ISSUED f (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 h 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. City Lot Size PM l Job Address ` ddress Phone Owner's Name Address nse N0.1774r Phone 1 r~ Contractor I TYPE OF WELL/PU aP-�_, NEW WELL WELL REPLACEMENT ❑ DESTRUCTION 0 PUMP INSTALLATIONS ., SYSTEM REPAIR ❑ OTHER.❑ I DISPOSAL FLD�ICA I PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK— SEWER LINES _ FOUNDATION: - -`AGRICULTURE WEL" �1'OTHER WELL PITS/SUMPS= - INTENDED USE TYP OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing ❑ Industrial pen Bottom ❑ Manteca Dia. of Well Excavation Specifications t ❑ Domesticl Private ❑ Gravel Pack ❑ Tracy Type of Casing Type of Grout�� M Public (] Other {1 Delta Depth of Grout Seal - I rrigation Approx. Depth I 1 Eastern Surface Seal Installed by H Repair Work Done. ❑ Type of Pump' P State Work Hone Well Destructidn ❑ Well Diameter _ _ .-- Sealing Material (top 50') r 9 I Depth Filler Material I Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRlADDITION l 3 DESTRUCTION�I;I (No septic systithin m perm available feetit�ed if public sewer is Installation will serve: Residence— Commercial Other ; f r Number of living units: Number of bedrooms r.. �" r 1 Water table depth Character of soil to a depth of 3 feet: ` SEPTIC TANK ❑ Type/Mfg Capacity � No. Compartments Method of Disposal PKG. TREATMENT PLT. ❑ ' . Distance to nearest: Well Foundation Property Line s l LEACHING LINE ❑ No. & Length of lines Total length/size i FILTER BED ❑' Distance to nearest: Well Foundation Property Line t SEEPAGE PITS I I Depth Size Number -SUMPS ❑ Distance to nearest: Well Foundation Property Line i DISPOSAL PONDS ❑y' `� ' " 1 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 agents 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." Contractol's 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 to workman's compensa- tion laws of California." The applicant m t call for all re ed spections. Complete drawing on_ verse isCe. Signed K Title: ' Date F. R DEPARTMENT USE ONLY Date Area Application Accepted by - 3 r r rDate, J � Final Inspection by Date Pit or Grout Inspection by - _ Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95241 CK RECEIVED BY DATE PERMIT NO. FEE AMOUNT DUE AMOUNT REMITTED CASH ` INFO 3 b {, +.EH 13.21(REV.1/H 5) EH 11-215 �"