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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/of 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. h Job Address City Lot Size " PM Owner's Name &&g Address Phone ��11 Contractor !tv .� dress4feLicense No. Phone E/ 4 TYPE OF WELL/PUMP: NEW ELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTAL TION ❑ 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 El Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications [f� M Public F1 Other Fl 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 Sealing Material Itop 5011 Depth Filler Material (Belo 1 TYPE OF SEPTIC WORK: NEW INSTALLATION t 1 REPAIRIADDITION Ir DESTRUCTION l I (No septic system permitted if public sewer is I available within 200 feet.) t Installation will serve: Residence x Commercial Other t Number of living units: .__...-__-,_ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg CapacityT No. Compartments PKG. TREATMENT PLT. ❑ i Method of Di o�saI Distance to nearest: Well 6V Foundation Property Line Re LEACHING LINE ❑ No. & Length of lines � . �` �0 ` �T�O Total lengthlsize� 7� FILTER BED ❑ Distance to nearest: Well Sr5 Foundation 17 Property Line— SEEPAGE ine—SEEPAGE PITS l I Depth Size 7� _ Number SUMPS Distance to nearest: Well 100f 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, ander rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following:-'T 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." Contractors 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 ust I or all require rns ctions. Com ete drawingo verse side. —� Signed X Title: �y 'Date: f _ _ FOR DEPARTMENT USE ONLY T -� ffJJ Application Acce ted by _ Dace �b sr Area / ffl S Pi�tGr� Inspection s ecti pection by Date Final Inspection by Date Additional Comments: '74k�,, Y 5' ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Nrantece 823-7104 ❑ Tracy 835-6385 Applicant - Return all cops to: EnvironTental Health Pe mit/Services 1601 E. Hazelton Ave,.,, P.O. Box 2009, Si ., CA 95201 7d t& W r// f'1r a f C'Oa�Gf �r r e tia/� 1"7:0f /11� 4'r 1'4,_r 3FEE INFO AMOUNT DUE AMOUNT REMITTED i CK CASH RECEIVED BY DATE PE��R77MIT"NO. +.EH 13-24(REv,1/K 5) [J i06 y+��jY� EH 14-28 LLJJ(( !!!!JJ II//