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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/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. t f ! 7 C ? -- g 5r- OAS U � z Job Address _.. �_ City pC Lot Size 3, 7YC PM i Owner's Name Address Phone Contractor's Name A A- &A- License No. d Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ I 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 Weil Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other 5 ❑ Delta Depth of Grout Seal El Irrigation _A Type of Grout --Approx. Depth ❑ Eastern Surface Seal Installed by 1 Repair Work Done ❑ Type oUpump•/_ H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material {top 50'} Depth Filler Materia! (Below 50') 4 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ lNo septic system permitted if public sewer is available within 200 feet.f Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth F SEPTIC TANK a Type/Mfg _� 4 Capacity p &9'd 0 No.I,Compartments PKG. TREATMENT PLT. ❑ Ca �'.. Method of Disposal Distance to nearest: Well 3 Foundation r Property Line 221 LEACHING LINE �' Q No. & Length of line Total length/size FILTER BED E.3 Distance to nearest: Well y oundation %d —� Property Line SEEPAGE PITS 94-- DepthJ , 'a fi Size .2— Number SUMPS ❑ Distarlde to nearest: Well 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 l i rules and regulations of the San Joaquin Local Health District. Home owner or.licensed agent's signs re 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 a become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature certifies the following:"I certify that' he performance of the work for which this permit is issued, I shall employ p p y persons subject to workman's compensa- tion laws of California." , The applicant c fo I r inspect! s. o lete dr wing on reverse-side. Signed tie: Date: w OR D PARTMENT USE ONLY Application Accepted by Date Arles ©/ it or rout Inspection by ate d Final Inspection by Date Additional Comments: ❑ Stk 466-6781 Lodi. 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-638.5 � Applicant- Return al copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED INFO J ' CASH RECEIVED BY DATE PERMIT"N0. t EH 13-24(REV,10/83) EH 1426