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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA n� f f Telephone (209) 466-6781 N10 Ws -d1. wfl y PERMIT EXPIRES 1 YEAR FROM-DATE ISSUED _ rr (Complete in,Triplicate) �" .• , , r 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�/� { Job Address} /v r . Cr , L.✓/fLrN Lot Size / / PM Owner's Name Address Phone Contractor � Address License No. Phone TYPE OF WELL/PUMP I� NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i PUMP INSTALLATION ❑ ySYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER-LINES DISPOSAL FLO. PROP..LINE 1 _ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS _ _ C1 Industrial El Open Bottom [J Manteca Dia. of Well Excavation Dia. of Well Casing 4 a ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done El Type of Pump H.P. State Work Done: I Well Destruction ❑ Well DiameterSealing Material (top 50') t f Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION EIREPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is IC available within 200 feet.) Installation will serve: Residence_ Commercial Other Number of living units: I Number of bedrooms Character of soil to a depth of 3 feet: J0Water table depth r] SEPTIC TANK Type/Mfg Capacity No. Compartments t PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ ' No. & Length of lines Total length/size n FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance 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 rules and regulations of the Sari 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." (I The applicant mus call for all required inspections. Complete drawing o reverse side. n J Signed I Title: r/`/ Date: G © � FOR DEPARTMENT USE ONLY Application Accepted by Date _1�0"a Area 19 Pit or Grout Inspection Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi'1, 369-3621 El Manteca 823-7104 ❑ Tracy 835.6385 Applicant - Return all copies toEnvironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO AMOUNT DUE AMOUNT REMITTED AS RECEIVED BY DATE PERMIT"NO.�, + EH EH 13-26 14-28 V.ti/R 51