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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 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 Local Health District. [� Job Address e City Lot Size �- PM Owner's Name Address` -- k ' Contractor AddresX-11� ! dA I"� License Nea42 Phone"-7 _? TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ m 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 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1-1 Public 11 Other ❑ Delta Depth of Grout Seal Type of Grout _ I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Weil Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION DESTRUCTION ( I (No septic system permitted if public sewer is '/ available within 200 feet.) Installation will serve: Residence/ Commercial.m._. Other ' Number of living units: Number of bedroo ms_.__.... \ Character of soil to a depth of 3 feet: =-= .r � �+� Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal ~ Distance to nearest: Well Foundation _ Property Line LEACHING LINE X, No. & Length of lines o Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Of Y' Property Line i + SEEPAGE PITS . Depth Size Number i1 SUMPS 1:1 Distance to nearest: Well �f Foundation Property Line �( DISPOSAL PONDS © ; n i1 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, an 1' rules and regulations of the San Joaquin Local Health Di1trict. 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 work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all requi ms rons. Complete drawing on revere side. Signed r '+ Title: Date: 1,9k FOR DEPARTMENT USE ONLY Application Accepted by µ Date Area /Pis/or Grout Inspection by Date Final Inspection by ate!z �v �� f Additional Comments: • 1 ❑ Stk 466-6781 ❑ Lodi 369r3621 ❑ Manteca 823-7104 ❑ Tracy 83 6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. +.EH1 -241REV.F;H51 /� !`{! t7 7 EH 144-215 NNN / U