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APPLICATIONFOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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 Ryles and Regulations of the San Joaquin Local Health District. �t I « = ��` � L� PM Job Address �– • _ r.G Ci `4 N5p( u77 Lot Size / Owner's Name Address Phone Contract aF Address �� Liceslse Noc Phone w: 1 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Q a s PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS II O Industrial C1Open Bottom ❑ Manteca Dia. of Well Excavation ^ Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications, 4 ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ElType of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top,50') i Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION i] DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Z Commercial_ Other / � Number of living units: –J— Numberbedroo n Character of soil to a depth of 3 feet: ' ti —' Water table depth p ' SEPTIC TANK Type/Mfg Capacity F No. Compartments � - - � Ca PKG. TREATMENT PLT. ❑ f� � '"""Method of Disposal I Distance to nearest: Well Foundation Property Line � i �. LEACHING LINE tri' No. & Length of lines, r a Total length/size ' y FILTER BED ❑ Distance to nearest- "/Well — 'Foundation Property Line �— r SEEPAGE PITS �* A Depth a _Size ---Number--- .. i SUMPS ❑�pistanc�to'nearest: Well /r2/) Foundation Property Line DISPOSAL PONDS ❑ f 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 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 work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California-" The applicant ust call for all requi ed inspections. Complete drawing on reverse side. Title: Y Date: Signed FOR DEPARTMENT USE ONLY Application Accepted by' Date Area it r Grout Inspection by (eTj "Date F Final inspection by Date �/ rV Additional Comments: &Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 . ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED `CASH - RECEIVED BY DATE PERMIT`NO. i INFO y' + ER 13-241AEV.1/851 LAS. ,�� k� 5-��-II EH 1426 if