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APPLICATION FOR PERMIT ,:i. SAN JOAQUIN 'LOCAL'HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 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 Ryles and Regulations of the San Joaquin Local Health District. Job Address ' 21 /�� City Lot Size PM Owner's Name }. Address Phone - t �y _ Contract Address License No Z Phone3�+5`��f a S. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ii PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. 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 ,❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Cl Public Ll Other >f LJ Delta Depth of Grout Seal Type of Grout _ � ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth 1 Filler Material (Below 50') �+ No septic stem rrnitted if public sewer is TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR DDITION DESTRUCTION ❑ 1 P Y Pe R available within 200 feet...), Installation will serve: Residence Yk Commercial_ Other Number of living units: = Number of b oms� Character of soil to a depth of 3 feet I _ Water tad e depth Q 4 SEPTIC TANK L1TypelMfg� �� No. Compartments PKG. TREATMENT PLT. ❑ f i. Method of Disposal f _,,� ,� Distance to :-��nearest: Well Foundation; 4 - Property Line f ` 11 4 i - <"fi ;✓ LEACHING LINE �No. & Length of•line`s� r Total lengthlsize ?< �, FILTER BED ❑ Distance to nearest: We{f ! Foundation �� r Property Line I -. I SEEPAGE PITS ❑ 'Depth ' I ISize .X' ��— Numb�� SUMPS l�Distance;-to nearest: Well ` �?D'. f Foundation __:Property Line t i 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, an 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 work for which this permit is issued,'I'shall not employ any person in such manner as to become subject to.wo'rkman's compensation,laws of California."Contractors hiring or sub-contracting signature certifies the following:"I certify that in the performance of 04 work for which this permit is issued, I shall employ person subject to workman's compensa- tion laws of California." T i t The applicant mcall for all r i inspections_Complete drawing on reverse side.or 11 1 r� .3 Signed X� "Title: �. Dater ic - FOR DEPART ENT USE ONLY i Application Accepted by Date Area i Pit or Grout Inspection by Date Final Inspection by Dat a Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104. ❑ Tracyy 835 ' Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,-Stk„ CA 95201 _. . FEE AMOUNT DUE.F AMOUNT REMITTED CASH RECEIVED BY ; DATE PERMIT`NO. INFO 6 1 + EH 1324[REV.I/e 5) _7n , EH 14-26 41 ,