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APPLICATION FOR PERMIT SAN JOAQUIN L0CAL-HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 ,PERMIT EXPIRES TYEAR FROM DATE ISSUED i (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 i Local Health District. �y / Job Address # LG n"` Cityy t-d1�fi-r/1*ot size PM -E d Owner's Name rr Address Phone j Contractor k ti �~!' Address i b a^y - License No.�- Phone_ TYPE OF WELL/PUMP: NEW WELL'❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ElSYSTEM REPAIR 1-1 OTHER C1 DISTANCE TO NEAREST: SEPTIC TANK i SEWER LINES DISPOSAL FLO. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL t PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing i ❑ Domestic/Private ❑ Gravel Pack ' ❑ Tracy Type of Casing Specifications +n 1 Public {:1*Orher — - '{_l Delta -Depih of Grout Seal Type of Grout �\ 1 Irrigation Approx, Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump'I H.P. State Work Done r Weil Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth Filler Material(Below 50'1 -- TYPE OF SEPTIC WORK: '. NEW INSTALLATION V REPAIR/ADDITIOW1 I DESTRUCTION I I INo septic system permitted it public sewer is j —t . available within 200 feet ) ,��..r..,,.�• i Installation will serve:_ Residence 7 Commercial_ Other Number of living units: + Number of bedrooms a Character of soil to a depth of 3 feet: Scn ,e^ *r Water table depth SEPTIC TANK Type/Mfg C fl h G{e-L- Capacityr a-Zm No. Compartments PKG. TREATMENT PLT. ❑ t Method of Disposal ` Distance to nearest:—Wellh�- -Foundation`-0 Property Linej� t I LEACHING LINE No. & Length of lines t Total length/size FILTER BED ❑ Distance to(nearest: Well Q_!Foundation �t7 r _ Property Line t r SEEPAGE PITS I I Depth I t Size _ Number SUMPS L� Distance to nearest:..- Well Foundation Property Line t 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 s gnature`cel tifies the following: 'T 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." r The applicant must call for allre fired inspections Complete drawing on reverse side. �J Signed X �/I �j__ Title: Date: FORD'POARTMENT USE ONLY Application Accepted by ' Date Areae ! Pit or Grout Inspection byDate Final Inspection by Dat 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 FEE AMOUNT DUE f AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH 1r �y E +.EH 1324 1 REV. x 5l Q 1Z� � t l EH 14-29 r i