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_ APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED t (Complete in Triplicate) Application is hereby made to the San the Rules and Regulations of the San Joaquin 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 welllpump and Local Health District. jc-- Lot Size PM City Job Address Address Phone Owner's Name t) Phone Contractor Address License No.�—� Contractor DESTRUCTION ❑ TYPE OF WELtIPUMP: NEW WELL ❑ WELL REPLACEMENT,❑ SYSTEM REPAIR ❑ OTHER ❑ PUMP INSTALLATION F7 SEWER LINES � DISPOSAL FLD. PROP. LINE I DISTANCE TO NEAREST: SEPTIC TANK PITS/SUMPS FOUNDA1. TION AGRICULTURE WELL OTHER WELL l INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications Type of Casing ❑ Domestic/Private ID Gravel Pack 1-3 Tracy Depth of Grout Seal Type of Grout — '' I F-1 Other Cl Delta r t`7 Public Ap0ox. Depth l I Eastern Surface seal Installed by I I irrigation — •I State Work Done — I Repair Work Done ❑ Type of Pump H,P. Beaking Material Atop 501 Welk Destruction Q Well Diameter f Depth Filler Material (Below 50'1 I TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIRlADDITION. DESTRUCTION l l alvailablerw thin 200 permitted if public sewer Is C, Installation will serve: Residencr3 1 Commercial_ Other Number of living units: Number; of bedrooms Water table depth Character of soil to a depth of 3 feet: No. Compartments SEPTIC TANK ❑ Type/Mfg Capacity i r`� Method of Disposal PKG. TREATMENT PLT. ❑ Property Line Distance to nearest: Well Foundation p Y 1 ' C No. & Length of lines _ Total length/size LEACHING LINE Property Line FILTER BED ❑ Distance to nearest: Well Foundation A / Z Number_ 1 SEEPAGE PITS Depth Siza rProperty Line SUMPS L1Distance to nearest: Well Foundation I 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: 11 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." 1 The applicant must tali for all req .red inspections. Complete drawing on reverse side. ^` Date: Signed X Title: ��0 FOR DEPARTMENT USE ONLY �( n Date 1 �a d `Area_•—�� Application Accepted by i P Date Final Inspection by Pit or Grout Inspection by Data_ Additional Comments: El Stk 466-6781 ❑ Lodi 369-3621 ❑ Mante 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 85201 FEE f CK RECEIVED BY DATE PERMIT NO. INFO AMOUNT DUE AMOUNT REMITTED CASH +.EH 13-24{REV.t/8!5) S� ; �� - J EH 14-2e