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PLICATION 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 r (Complete in Triplicate) App cation 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 ma in compliance with San' oaquin County Ordin a No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Loc Health District. r i Jo Address I r City Lot SizePM Owner's Na "l Ad ess Phone Contra ddress License N 2� phone J CU k TYPE OF WELL/PUMP: II NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE-TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. _ PROP. LINE t FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS M� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS x` ❑ Industrial ❑'k pen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing r } ❑ Domestic/Private ❑ ,Gravel Pack ❑ Tracy Type of Casing Specifications j 11 Public 171 `Other Cl Delta Depth of Grout Seai Type of Grout- t I Irrigation - =�I.-Approx. Depth { I Eastern Surface Seal: Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done ' Well Destruction ❑ Wel! Diameter Sealing Material (top 501 ` V Depth Filler Material (Below 50') `"'+�� @ TYPE OF SEPTIC WORK: NEW INSTAL TION RFPAIRlADDITION I I DESTRUCTION-I`I INo septic system permitted if public sewer is ' available within 200 feet.i Installation will serve: Residence_ Commercial they w Number of living units: Number of a ooms Character of soil to a depth)of 3 feet: Water'table depth 14 u t SEPTIC TANK /V- Type/Mfg Capacity No..Cornpartmenls t PKG. TREATMENT PCT. ❑- Method of Disppsal i'! Distance to nearest: Wel / 5f` Foundation Property.Line // F ti , 4 LEACHING LINE ❑ I'No. & Length of lines X �, ' . Total lengihlsiz x 4.t1 : '� fry ap y � FILTER BED I� ADistance to nearest: W /Q0 Foundation ell Proert Line /Lp• a" k SEEPAGE PITS I I Depth Size' Number SUMPS ❑ `D stance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 7 = I hereby certify that I have prepa d this application and that theworkwill be-done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. k' Home owner or licensed agent's signature certifies.the following: "I certify'rthat in the performance of;the work for which this permit is issued, i shall not k employ any person in such manner as to become.subject.to workman's compensation Jaws_of California." Contractor's-hiring-or-sub-contracting-signature I� k certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall emptoy.persons subject to workman's compensa- tion laws of California. _ The applicant t call for all�rVqed spec tions. Complete drawinrevers s' g on reve Signed Title: - Date IM z y FOR DEPARTMENT USE ONLY ion Acce Application y �P Date Area _12— Pit _1 2 Pit or Grout Inspection by I� Date Final Inspection by Dat Additional Comments: I� © Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-fi385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO AMOUNT DUE AMOUNT REMITTED CAC" RECEIVED BY DATE PERMIT'NO. FEE` - go 8� +.EH 13-24 1 REV.I/a 51 ' EH[4-2t1