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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE i ON AVE., STOCKTON, CA i Telephone 1209) 466-6781 PERMIT EXPIRES 1-YEAR FROM DATE ISSUED 1_1 (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct ell/pu 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. 1 �' Jab Address l 1 a �f, L�� City /A� Lot Size ✓• PM _� Owner's Name ��-- I S Address _ ! 4r Phone�D�" Address -3 �� License No.* Phone Contractor , TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ T, SYSTEM REPAIR ❑ OTHER ❑ j DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. 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 ' T e of Casing Specifications 11 Domestic/Private ❑ Gravel Pack ❑ Tracy E Yp 9 ("1 Public 1-1Other C: Delta Depth of Grout Seal Type of Grout I 1 Irrigation _Approx: Depth I 1 Eastern i Surface Seal Installed by r H P. State Work Done Repair Work Done ❑ Type of Pumpr Sealing } Weil Destruction 11 Welt Diameter g Material Itop 50'I Depth Filler !Material lBelow 50'1ed �� Q IF TYPE OF SEPTIC WORK: NEW INSTALLATION R 'PAEPAIR/ADDITION l I DESTRUCTION I I alvailabptic system m feet.) rf public sewer is Installation will serve: Residence' Commercial z _Other Number of living units: Number of bedrooms2 S i Water table depth Character of soil to a depth of 3 feet- SEPTIC SEPTIC TANK ❑ Type/Mfg` Capacity_. No. Compartments PKG. TREATMENT PLT. L1 °i !nn'�b..��t / Method of Disposal L Distance to SO nearest: _Well'C�e Foundation D Property Line W y LEACHING LINE V�No. & Length of lines / Total lengthlsize FILTER BED ❑ Distance nearest: We11��_.�_ Foundation J Property Line 30 SEEPAGE PITS I I Depth _Size �K _ Number f i SUMPS L-1 Distance to nearest: Well C FoundationQ ( Property Line —� DISPOSAL PONDS ❑ 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 Dibtrict. 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 r 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 required inspections. Complete drawing on reverse side. Signed X_ Title: Date: I FO RTMENT USE ONLY Appli t' Ac ted by Date ''+� Area —— ` �ti Date P' or Grout Inspection by bate Final Inspection b i Additional Comments: CS I ❑ 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 i FEE AMOUNT DU€ AMOUNT REMITTED CK µ RECEIVED BY DATE PERMIT*NO. l IN �if'r +.EH 13-241REV.riKsr EH 14.26 f