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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT l 1601 E. HAZE T ON 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 Rules and Regulations of the San Joaquin Local Health District. 1;, ." • '' 9 ,j Ptd. DFr, 2 City L OD Lot Size '��`/ /4 PM Joh Address - 1`1- r L J Drx Phone Owner's Name Address ` License No. 3 0 9-7 Phone Contractor's Name Q` `�`�� A)`- ' TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 11 DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR E3OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK/ SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATIONI AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing Q Industrial [7-0pen Bottom ❑ Manteca Dia. of Well Excavation Specifications\V ❑ Domestic/Private ❑ Gravel Pack4 Q Tracy Type of Casing Type of Grout 171 Public ❑ Other ❑ Delta Depth of Grout Setif ❑ Irrigation �Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H P State Work Hone Well Destruction Q Well Diameter Sealing Material (top 501 ' Depth Filter Material {Below 50'} TYPE OF SEPTIC WORK: NEW INSTALLATION Q REPAIRIADDITION DESTRUCTION ❑ available 1wthin 200 feet.) if public sewer is Installation will serve: Residence✓ Commercial_ Other �It t Number of living units: J.— Number of bedrooms-3— water table depth Character of soil to a depth of 3 feet: I Qth.. a°^'" No. Compartments SEPTIC TANK El Type/Mfg I Capacity Method of Disposal E ' PKG. TREATMENT PLT. ❑ Property Line Distance J nearest: qo Well Foundation (-� Total length/size- LEACHING ength/'size LEACHING LINE [� No. & Length of lintel I ��} } FILTER BED ❑ Distance to nearest: Well�— Foundation ��( Property"`Line tl Number Size - I SEEPAGE PITS Depth S1Zg �a! Property Line SUMPS" ❑ Distance to nearest: Well 0 Foundation DISPOSAL PONDS Q1^ I I hereby certify that l 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 n to become subject to wbikman'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 employ persons subject to workman's compensa ition laws of Californla.''-%��, f The applicant must call r all required inspections. Complete drawing on reverse side. # 3 4s�3 f; �- d Date: e — Signed '' Title: ! FOR DEPARTMENT USE ONLY Date Area Application Accepted by —&�i Date Final Inspection by Date ' Pit or Grout Inspection by ---- p/ Additional Comments: X ❑ Stk 466-6781 Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copi o: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box2009, Stk., CA 95201T} CK" "`g E-� RECEEIVE6- Byl] DATE PERMIT"NO. FEE AMOUNT DUE AMOUNT REMITTED') CASH F + EH 1324{REV.10!831 INFO EH 14-28 m .