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APPLICATION,FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ` 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 7� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 'Complete in Triplicate} f 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. h r; Job Address �'� s *- City `. Lot Size PM raT ��iy 2 � Phone Owner's Name Address t Contractor's Name- License No. Phoned I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER LJ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL.FLD.T PROP. LINE t FOUNDATIONS . r'FiCRICUI~TURE WELL `•. 'OTHER WELL PITS/SUMPS 4'��`INI'Ead{3LDUSE"""""^�Tl'PE'OF`VIIECL` `PROBLEl111AREA-""C fRUCTIONSPECIFICATIOiVS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy 'Type of Casing Specifications ❑ Public ❑ Other { ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern_ Surface Seal Installed by Repair Work Done ❑ Type of Pump -'"+H.P.i } w State Work Done Well Destruction ID Well Diameter Sealing Wterfal (top-50')_ _ �J ] L Depth r Filler Material Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION 0` REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is x available within 200 feet./ r Installation will serve: Residence_ Commercial— .Other Number of living units:, Number of bedrooms f Character of soil to.a depth of 3 feet: F Water table depth f SEPTIC TANK . _ Ehf Type/Mfg, p _ Capacity No. Compartments PKG. TREATMENT PLT. E3 Method of Disposal I ' Distance to nearest: Well Foundation Property Line LEACHING LINE:' ❑ jNo. & Length of lines Total length/size FILTER BED 0 j,Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ DeptFi Size Number SUMPS ❑ Distance to nearest: Well Foundation '� Property.Line DISPOSAL PONDS ❑ 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. I + `* 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." 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- tion laws of California." The applicant st call for all required inspect'ons. Complete drawing on reverse side. 1 Signed Title: — Dater FOR DEPART ENT USE ONLY ' Application Accepted by �/ Date t� Area r J Pit or Grout Inspection by `' Date Final Inspection by Date! 31 ffn< Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369421 -❑ 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 ii I,t FEE AMOUNT DUE` AMOUNT REMITTED CK RECEIVED BY BATE PERMIT"NO.' INFO p� s, l + EH 1}24(REV.10183) ,r ' .� �Q -7�15/C6 EH 1428 V l..