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APPLICATION FOR PERMIT 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) 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. r i Job Address . Cit 4aof Size PM Owner's Nam Address Phones- 3 [� Sip Contract Address License No Z Z6Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ fi PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ s' DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES DISPOSAL FLD. PROP. LINE t s FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1 I rF ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia- of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications l f'] Public Li Other n Delta Depth of Grout Seal Type of Grout I I Irrigation --Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 Death Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION -f1EPAIR/-ADDI.T.ION kl'�DESTRUCTIOk II I INo septic system permitted if public sewer is "� available within 2t�feet.} 1. v ✓ Installation will serve: Residence Commercial— Other LA Number of living units: _/_ Number of be rooms Character of soil to a depth of 3 feet: V4/a er table depth SEPTIC TANK Type/Mfg .,'d-a acit o. I P— Yy� - No. Compartments PKG. TREATMENT PLT. ❑ i Method of Dispo al Distance to nearest: Well. rte Foundation s--property Line__ S LEACHING LINE No. & Length of lines �t . . Tota! length/size FILTER BED ❑ Distance io nearest: Well Foundation�/9�-- property Line ter' •.:...1• 1 i 1 t. l SEEPAGE PITS l I Depth ( SizeNumberC� - SUMPS ❑ Distance to nearest: , Well Foundation ! Property Line --- 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, and rules and regulations of the San Joaquin Local Health District, i 4 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 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." �/f i k The applicantm call for all r q ed spections. Complete drawing on reverse�lid,� t I f Signed X Title: i Date: 01" I . .-_FOR-DEP-ARTMILNT.JSE Application Accepted by Date Area 2— Pit or Grout Inspection by t # Date Fihal Inspection by Date r Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 r Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE \` CK INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE Z�PERMW'140. +,EH13-21(REV.I/x 51 /1-Il/j EH 11-26