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` APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALT14 DISTRICT 4 1601 E. HAZELTON-AVE., STOCKTON Telephone (209) 466-6781 CA -PER AIT EXPIRES 1 YEAR FROM DATE ISSUED�nd r r v: (COmplete in Triplicate) t Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or instal!the work herein r 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 Local Health District, described. This application is Joaquin Job Address, -- City �/� Lot Size L © i 4 4 - PM - Owner's Name � - Address Contractor's Name /�� Phone TYPE OF WELL/PUMP: icense No. / NEIN WELL ❑ WELL REPLACEME ❑ — Phone PUMP INSTALLATION El WELL ❑ DISTANCE TO NEAREST: SEPTIC TANK SYSTEM REPAIR ❑ OTHER ❑ SEWER LiNES �_�� DISPOSAL FLD.__ FOUNDATION AGRICULTURE WELL � — PROP. LINE INTENDED USE TYPE OF WELL OTHER WELL PITS/SUMPS rt ❑ Industrial PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Open Bottom ❑ Manteca '-� -- t ❑ Domestic/Private El Gravel Grave! Pack r3ia�ofsWell.Excavati_on�,��- Dia. of Well Casing ❑ Public Type of Casing 1 ❑ Other ❑ Delta Specifications F. ❑ Irrigation Dep#hyaf Grout Seal ---Approx. Depth ❑ Eastern Surface Seal Instoted by_ Type of Grout_ Repair Work Done 11 Type of Pump E� Well Destruction ❑ Well DiH.P. State Work Done Diameter Sealing Material (top 50') Depth Filler Material (Below 50') f INN TYPE OF SEPTIC WORK; NEW INSTALLATION ❑ REPAIR/ADDITION ❑ .DESTRUCTION [9 (No septic system permitted Installation will serve: Residence P ited if public sewer Is fr e ci #available within 200 feet.) _ l Commercial Other Number of living units: ? Number:of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK ClType/Mfg. *R `"' Water table depth) PKG. TREATMENT PLT. [II�Pa �' � No. Compartments d Distance to nearest: Well ,d y " Method of Disposal I FoundationsProper Fine LEACHING LiNE "o, & Length of lines FiLTER BED a �gih/size ; — ❑ Distance to nearest: Well �,/�� t Foundation Property Line ' _ SEEPAGE PITS ! # } � depth X Size SUMPS ❑ Distance to nearest: Number DISPOSAL PONDS ❑ Wel! — Foundation ��'' �� Property fine� t I hereby certify that I have prepared this application and that the work will be done in accordance with San Joa uin coun rules and regulations of the San Joaquin Local Health District, 1 - Home owner or licensed agent's signature certifies the following: q ri ordinances, state laws, and ' employ an g: '9 certify that in the performance of the work for which this permit is issued, I shall not p Y y person in such manner as to become subject to workman's compensation laws of California."•Contractors 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° m`to tion laws of California." u p Y persons subject to workman's com ` The applicant must call for a I requi spections. Com to drawing on reverse side. pensa Signed Title: M /'® Date: � >45R DEPAR N USE ONLY Application Accepted by +� .J Date a Pit or Grout Inspection byep j . Date Final Inspection by Additional Comments: - �� date ❑ Stk 466 6781 ❑ Lodi 359-3621 ❑ Manteca 823-7104 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E.azelton Ave.,Tracy P.O. Box 2009 Stk., CA 95201 i� a FEE AMOUNTDUE CK y f INFO AMOUNT REMITTED RECEIVED BY 1 CASH l0 ATE PERMIT"NO. 1 W24(REV,10/83) -