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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT t 1601 E. HAZELTON AVE:, STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED E. (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 welllpump and the Rules and Regulations of the San Joaquin Local Health District. ! PM Fjy3 > City c.G Lot Size Job AddressJ�Z_M- of! �_ ` DC_'pn.oYct.� Address Phone �i7wner s_Name„T - _ Phone Contractor r ( . Address License No. �7 PE,OF_.WE;LL/P„UMP:. . V, NEW,WELL LJWELL_REPLAC_EMENT ❑ DESTRUCTION ❑ � - PUMP INSTALLATION ❑~ Ym T,- SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NE SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 3 f TION AGRICULTURE WELL: OTHER WELL PITS/SUMPS -INTENDED USE TYPE OF WELL ROBLEM AREA CONSTRUCTION SPECIFICATIONS ` ❑ Industrial ❑ Open Bottom ❑ Man Dia. of Well Excavation Dias of Well Casing `� } i Specifications I s ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy y asing r f`1 Public 17 Other Ll Delta Depth of Grout _ TYPe of Grout ..... T u I ('Irrigation -1- —_.Approx.1 Depth I 1 Eastern r 5uriace S. Installeii by t e of Pump -H.P. State Work Done `. Repair Work Done ❑ Type c Well Destruction ❑ Weil Diameter Sealing Material (top 501 Depth Filler Material (Below 501 s TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is y A available within 200.feet.) Installation will-serve:"Residence Commercial Other rNumber of bedrooms Number of living units: Water table depth t Character of soil to a depth of 3 feet: F �'` SEPTIC TANKS Type7Mfg” 'L - apacity_ TSC� ��—No`Compartments"”" Method of Disposal PKG. TREATMENT PLT. 171 Distance to nearest: Well Foundation .— Property Line — , R r LEACHING LINE No. & Length gth of lines Total length/size FILTER BED `"'❑i Distance to nearest: We11 Foundation Property Line�— . SEEPAGE PITS - 1 1: Depth I Size Number SUMPS 6� Distance oto nearest: Well Foundation Property tine 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 District. r Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the employ any person in such manner as to become subject to won work for which this permit is issued, I shall not workman's compensation laws of California." Contractor's hiring or sub-contracting signature P ersons subject to workman's compensa certifies the'fbllo-wing�(,certify that in the performance of the work for which this permit is issued, I shall employ p 1 tion laws of California.'F The applicant must call for all requir d inspections. Complete drawing on reverse side. I ¢ I Signed X Title: Date: + F PARTMENT USE ONLY Application Accepted by Date Area ► r / Date Pit or Grout Inspection by Date Final Inspection by Additional Comments_: - © Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 C1 Tracy 835-6385 a Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 CK 9 _ FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PPEj !JRJMIT'NOQ k k Z_N_FO 0{ �f "_ 0(73.24(REV.1/H 5) "' 1'�EH 1426--,.-...-T+—. _ --- ---- 4