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I � F . APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA l/ Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) ISO , 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. `f • r. rna Joh Address / � " City � �/� Lot Size PM Owner's Name '�l7/�GQ� Address /y ��1 �� f/� Phone Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ S N r I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DI PROP. LINE ' FOUNDATION AGRICULTURE OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBL A CONSTRUCTION SPECIFICATIONS ! �, ❑ Industrial ❑ Open Bottom anteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel r ❑ Tracy Type of Casing Specifications r f'1 Public er {7 Delta Depth of Grout Seal Type of Grout I I Irrigation _..Approxi Depth I I Eastern Surface Seal Installed by _ Repair Work D e U Type of Pump H.P. State Work Done r Well Destru ion ❑ Well Diameter Sealing Material Itop 50') i Depth Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIR/ADDITION I I DESTRUCTIO 1 (No septic system permitted if public sewer is available within 200 feet.) Installation will serve:' Residence Y_ Commercial_ Other Number of living units: rNumber of bedrooms Character of soil to a depth of 3 feet! ¢ Water table depth r SEPTIC TANK Type/Mfg Capacity ='� No. Compartments t PKG. TREATMENT PLT. ❑ Method of Disposal T Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED r' ❑ 'Distance to nearest: Well a Foundation Property Line SEEPAGE PITS I I Depth Size Number 4 SUMPS Cl Distance to nearest: Weil 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 II 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." 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 must calleof all re wired "nspections. Complete drawing on reverse side. f "7 Signed X-� C �j Title: �— T �/ i Date: OR A ENT USE ONLY Application Accepted by Date �~ .. v� Area O Pit or Grout Inspection by Date Final Inspection by 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. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 r i4 INFO FEEAMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERM17'NO. + EH13-2R{FlEV.t/n51 S�V ' EH 14-26 4 1