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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA t Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i (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 wall/pump and the Rules and Regulations of the San Joaquin f Local Health District. � QJ Job Address 111—�-1 �a �� " C" Lot Size / �-�f L PM 6Owner's N Address �__T--. ---_ Phone aU j Contract Address& 76 7 License No. Phone { TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i� PUMP INSTALLATION C SYSTEM REPAIR El OTHER ❑ DISTANCE TO NEAREST:iSEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE 1 TYPE—OF—WELL -PROBLEM AREA—CONST49UCT4ON•SPECIFICA-BONS ❑ Industrial ElOpen Bottom C Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private C Gravel Pack ❑Tracy Type of Casing _ Specifications ❑ Public . C 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 r� Well Destruction C Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') — TYPE OF SEPTIC WORK: NEW INSTALLATION Rr REPAIR/ADDITION D DESTRUCTION ❑ (No septic system permitted if public sewer is - - " available within 200 feat.) Installation will serve: Residence m Comercial- -Other- Number OtherNumber of living units: 4— Number of bedrooms —3 l 7 Character of soil to a depth feet: Water table depth ` SEPTIC TANK Type/Mfg Capacity 6l No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal '+ Distance to nearest: Well �;t Foundation I IV 'e_ Property Line LEACHING LINE No. &Length of lines 3 g ��! Total length/size r FILTER BED ❑ Distance-to nearest:. Well 5� Foundation L- Property Line � i SEEPAGE PITS ❑ Depth t Size Number ' SUfv PS' ❑ Distance to nearest: Well 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,.stateJaws,-and rules and regulations of the San Joaquin Local Health District" Home owner or licensed agent's signature certifies the fMoMng: "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."Contractor's hiring or sub-contracting signature certifies the following:"I cbrtify that in the performance of the work for which this permit is issued,I shall employ puns subject to workman's compensa- tion laws of California." The applica *must call f II required inspections. Complete drawing on reverse si Signed ~ + � J �ll� Title: Date: t '- FOR DEPARTMENT USE ONLY 11 Application Accepted by Date �— A etZ Af Pit or Grout Inspection by Date final Inspection by DASA Additional Comments: ❑ Stk 466.6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835 Applicant-,Return all copies to: Environmental Health ParmitlServices 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO" INFO . EH 13-241REV.vu 6) Q��o -533' EH 14-26 .. i