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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL.HEALTH DISTRICT 1601 E. HAZETON 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 c.,.,-Inanuin Co ty Ordinance No.549 for sewage orrNo. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. y _ "C_ Dr. .ri YOB Job Address City C000 Lot Size � PM Owner's Name G 6`Y Address Phone Contractor_=4- 1.. rc"jl6 r Address Alzs 19 '� --L � License No. Phone TYPE OF WELL/PUMP: 'NEW WELL ❑ WELL R CACEMENT El 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 Ll Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing L7 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ; ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation g —Approx. Depth [D 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 Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION Q (No septic system permitted if public sewer ist i I L available within 200 feet.) Installation will serve: Residence— Commercial— Other Number of living units: Number of bedrooms t ` Character of soil to a depth of 3 feet: Water table depth 1-3 "V SEPTIC TANK Type/Mf E- Gf 9 Capacity �� No. Compartments PKG. TREATMENT PLT. ❑ + Method of Diyosal I t Distance to nearest: Well f a Foundation r Property Line s�d LEACHING LINE ❑ No. & Length of lines —3 bt h e m— Total length/size ` FII,TER BED ❑ Distance to nearest: Well OC)4- Foundation Property Line V C SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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. Horne 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 mus call f r all r fired inspections. Complete drawing on reverse side. Signed Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by e r Final Inspection by Fi'a u J Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 El Manteca 623-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO 'AMOUNT DUE AMOUNT REMITTED CKi CASH RECEIVED BY ; DATE PERMIT NO. ' + EH 1&24(AEV.t/65) I- �` j EH 1426 c <ZA 1 ^` r 1v r