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APPLICATION FOR PERMIT t SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 , PERMIT EXPIRES T YEAR FROM DATE ISSUED (Complete in Triplicate) Application is heieby 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. C Or.i' 7_2 QC pk.c City 4 k Lot Size PM Job Address s Owner's Name �3 �r v _edk Address 2 T Q sp4r2 o Phone Contractor It Address License No. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ I` PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ , DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FCD. POOP. LINE I' 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 I Private i ❑ Gravel Pack ❑ Tracy Type of Casing Specifications !) M Public n Other ❑ Delta Depth of Grout Seal _ ... Type of Grout I I Irrigation ! _..Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State WorkDone Well Destruction El Well Diameter Sealing Material (top 50') t it Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION 1 1 DESTRUCTION I 1 (No septic system permitted if public sewer is available within 200 feet.) Installation will se IL Residence Other 1). ' /C ! Number of living units: _J__J_ Number'of bedrooms .j4 k d Water table depth Character of soil toy,a depth of 3 feet: ' � SEPTIC TANK 'I� Type/Mfg! Co it c h 4- Capacity /2 0 0 No. Compartments 2 a PKG. TREATMENT PLT. El .} Method of Disposal Distance to nearest: Well /o r Foundation _ .-.— Property Line LEACHING LINE No. & Length of lines Tgtal length/size i FILTER BED ❑ Distance to nearest: Well ©0 Foundations S Property Line r SEEPAGE PITS I I Depth I Size _ Number ;, f SUMPS D Distance to nearest: Well Foundation Property Line DISPOSAL PONDS' ❑ 4 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 I rules and regulationsp'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 A such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature r 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 s call for I required ins ctions. Complete drawing on reverse side. :. Signed Title: Date: �� FOR.DEPARTMENT USE ONLY r �j Application Accepted by ` Date r /�u Area D i Pit or Grout Inspection by N Date Final Inspection by f r Date Additional Comments: ❑ Stk 466-6781 11 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 i Applicant - Return all copies to: Environmental Health Permit/Services 1601.E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 , FEE IAMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO �p17-1 + EH 13-21(REV.I/H 5) Z / cJ0 " 3 EH 14-2a L