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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ,, I 1601 E. HAZEL T ON AVE., STOCKTON, CAS )) Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE I ...:;.- (Complete in Triplicate) e ` Application is hereby made to the San Joaquin Local Health.District for a permit to construct and/or in t it thl'work herein'describ2d.-This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump a d the Rules and Regulations of the San Joaquin i Local Health District. Job Addres /p` /f iL.L.A4eWrL City Lot Size PM r + Owner's Name Address Phone Contractor t — _AddressCL' L!� � ense No.'�1kq �' Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT LI DESTRUCTION ❑ 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 L1 Industrial El Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing VoomesticlPrivate ❑ Specifications Pack ❑ Tracy Type of Casing P 17 Public Ll Other *1 M Delta Depth of Grout Seal Type of Grout--_ I rout — I I Irrigation �_Appfox Depth t I Eastern Surface Seal installed by Repair Work Done Type of Pump H.P. State Work Done �� Well Destruction ❑ Weil Diameter e t Seating :Material {top 50') Depth Filler Material'IBelow 50')) TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION T I-`DESTRUCTION1 1 INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_I Commercial_ Other -� Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth -.SEPTIC'TANK ❑ Type/Mfg Capacity No. Compartments V t PKG. TREATMENT PLT. L1 Method of Disposal s Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines w Tata) length/size II FILTER BED ❑ Distance to nearest: Well Foundation Property Line — SEEPAGE PITS i I Depth.'i Size _ Number SUMPS 0 Distance'to nearest: Well Foundation Property Line. E DISPOSAL PONDS ❑ ' " i[ 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 Di%trict. 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, l shall not employ any person in such manner asIto 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 parsons subject to workman's compensa tion laws of California." + The applicant mus call for ill quired inspections. Complete drawing on reverse side. Signed Title:.. Date: " 4. FOR DEPARTMENT USE ONLY 16-5 ll Application Accepted by Date r J Area Pit or Grout Inspection by I Date Final Inspection by Date Additional Comments: I ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 FEE AMOUNT DUE AMOUNT REMITTED -CASH RECEIVED BY DATE PERMIT"NO. INFO +.EH13-241REV.I/K5r EH 14-29 E