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y APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT I �O 1601 E. HAZEL T ON AVE., STOCKTON, CA r Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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 E� 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. Job Address `' �V City Lot Size PM Owner's Name rel Address v`'' � ` Phone Contractor`%z= Acfdresss�I__J.- .4 .1 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Q Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications V? 1 Public (� Other I Delta Depth of Grout Seat Type of Grout I I Irrigation _-Approxi Depth I ) Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth t Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION [.I DESTRUCTIONI (Noseptic system permitted if public sewer is y available within 200 feet.) Installation will serve: ~Residence; Commercial Other Number of living units: Number of bedroom_s- _.: .. - Character-of soil to a depth of 3 feet.. Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ �. LLJJ I ^ Method.of Disposal i Distance to nearest: Well Foundation Property line LEACHING LINE' Cl No. & Length of lines 'Total length/size FILTER BED ❑y Distance to nearest: Well Foundation Property Line ] SEEPAGE PITS I i Depth Size _ Number SUMPS L-1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 11 h hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, statelawsand 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, 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 certify that in the performance of the worts for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." [ i The applicant m t call for all ired in tions. Co plete'drawing on.reve se side. Signed X ' Title: f Date: FOR DEPARTMENT USE ONLY Application Accepted byDate, ,^ Area Pit or Grout;Inspection by _ Date Final Inspection by Cry I `AKtional Comments: x ] Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6365 A plicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED INFO CASH RECEIVED BY DATE PERMIT N0. >Y; + EH 13-241REV.1/851 �(� ��3 �� EH 14-28 /!_