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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA f 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 Districts Zolf �� _ City Lot Size PM Job Address f Owner's Name Address c5 3 St.ic,.a� Phone t � 3 -V Contractor 3 License No. Phone_ Contractor Address I. TYPE OF WELL/PUMP:. NEW WELL, WELL'REPLACEMENT ❑ DESTRUCTION ❑ ,3- 1. PUMP INSTALLATION ❑ } SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES �` DISPOSAL FLD. PROP. LINE FOUNDATION t "k` AGRICULTURE WELL OTHER WELL PITS/SUMPS 143 INTENDED USE TYPE OF WI`tL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �''VV`J W El Industrial ❑ Open Bottom LJ Manteca,_...,..Dia. of Well Excavation Dia. of Well Casing c - r l LJ Domestic/Private 11 Gravel Pack ❑ Tracy Type of Casing Specifications W 17 Public 171 Other � F1 Delta Depth of Grout Seal Type of Grout I I Irrigation _.-Approx Depth I-I" astern -� Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Wel! Diameter s Sealing Material Itop 501 z' Depth j Filler Material (Below 50'I ` TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR 1.1 DESTRUCTION available within shin system rmiitted it public sewer is { , F t1� Installation will serve: Residence" Commercial_ Other Number of living units: Number of bedrooms + Water table depth Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg No. Compartments PKG. TREATMENT PLT. ❑ 3I t Method of Disposal r Distance to nearest: Well }Foundation Property Line \ _ LEACHING LINE ❑ No. & Length of lines s Total length/size \V r �] FILTER BED ❑ Distance to nearest: Well Foundation Property Line �. r SEEPAGE PITS I I Depth Size i — Number i SUMPS ❑ Distarice to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ "� - ! 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. z ,6/J1.�� Signed X Title- Date: s 4 —~— -- � --r— —•-�-FOR--DEPARTMENT USE-ONLY- - Date � .Area Application Accepted by � Pit or Grout Inspection Date Final inspection by f Date Additional Comments: ❑ 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 k FEE AMOUNT DUE TAMOUNT REMITTED C RECEIVED BY DATE PERMIT NO. INFO b +.EH 13-241REV.1/ms) - EH 14-26 -.