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i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 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 C' Lot Size PM 'I Owner's Nam Address Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACE NT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM EPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER IVES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICUL URE ALL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA NSTRUCTION SPECIFICATIONS D Industria! C1 Open Bottom El Manteca D . of Well Excavation Dia. of Well Casing 0 Domestic/Private ❑ Gravel Pack CI Tracy Typ of Casing Specifications FI Public ❑ Other Cl Delta Dept of Grout Seal Type of Grout _ I Irrigation Approx. depth I I Easter Surfac Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 0'1 Depth Filler Material (Below TYPE OF SEPTIC WORK: NEW INSTALLATION1. REPAIR/ADDITION t 1 DESTRUCTION.I I•(No septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence I Commercial Other Number of living units: 4 Number of bedrooms 4 Character of soil to a depth of 3 feet: — �-- _ `�'" '"�"'" Water table depth SEPTIC TANK Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method-of Dispos I Distance to nearest: Well t'LOb Foundation Property Line—1- V T LEACHING LINE No. & Length of lines Total length/size OL FILTER BED ❑ Distance to nearest: Well__-11)9* Foundation { 6, 'T-"Property Line = t SEEPAGE PITS {r f Depth S Size Number 3 f SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ f+ 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 st call f all req spections. Complete drawing on reverse side. i Signed X Title: Date: (��p � =RTMENT USE ONLY Application Accepted by _ �l�{ C v`^ ' INN&SA X�, Date Area 4 Pit or Grout inspection by Date Final Inspection by J Date lo—!d` Additional Comments: �" ✓ T� /> J ❑ Silk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6365 Applicant - Return all copies to`. Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 ii FEE i INFO WOUNT DUE AMOUNT REMITTED DASH RECEIVED 13Y DATE PERMIT'NO. I +.FH 13-24 tRl€V,1 i H 5) V .� {{ EH 14-26 D .0