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Y APPLICATION FOR PERMIT ` k— . SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (2091 466-6781 t PERMIT EXPIRES TYEAR 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. Job Address �. _- City Lot Size...,u,.. Owner's Name �d � Address ✓a Phone Contractor se"ice t Address �1 6-1�1 e License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ 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 V#1 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia."of"Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack Tracy Type of Casing Specifications ❑ Public ❑ Other i� ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation --Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump. H,P. State Work Done Well Destruction ❑ Well Diameter Seating Material (top 501 j Depth I Filler Material (Below 501 1 TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIWADDITION 1.1 DESTRUCTIONINo septic system permitted if public sewbr is W { vailable within 200 feet.] . Installation will serve: Residence 1 Commercial Other r _ Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: I Water table depth SEPTIC TANK C1Type/Mfg `� Capacity . No. Compartments «t "' PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size I FILTER BED ❑ Distance to'nearest: Well Foundation Property Line t� SEEPAGE PITS I I Depth I Size _ Number Ir SUMPS L-] Distance to-nearest: Well Foundation Property Line 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. 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." } The applicant must call for all required inspections. Complete drawing on reverse side. {� Signed X �in2sQ� . sV' Title: do LU A)a Data: FOR DEPARTMENT USE ONLY Application Accepted by Date Area 1 Pit or Grout Inspection by { Data Final Inspection byDa to Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-36211 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/ServiCB5"1601 E, Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 r IFEE AMOUNT DUE F AMOUNT RRE`MITTED ASH a/ CK A RECEIVED BY D[A]TE PERMITNO. + EH13241REV.iiHsl S 7 U6 6k ZZ) 3-/-V " - T EH 14-29 ✓ v�