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APPLICATION,FOR PERMIT SAN JOAQUIN LOCAL-HEALTH DISTRICT 1601 E.,HAZEL 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. Job Address✓ Rit Lot Size. PM E i Owner's Name Address Phone l Contractor's Name 1 License No. �f Phone TYPE OF WELL/PU P: NEW WELL ❑ WELL REPLACEMENT ❑ -DESTRUCTION ❑ tI, PUMP INSTALLATION ❑ SYSTEM REPAIR ❑- OTHER ❑ DISTANCE.TO NEAREST: SEPTIC TANK SEWER, LINES ..-DISPOSAL FLD. PROP. LINE FOUNDATION 'AGRICULTURE WELL OTHER WELT PITS/SUMPS INTENDED USE TYPE,OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i 1 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation pia. of Well Casing ` ❑ Domestic/Private El Gravel Pack—`_ _10 Tracy Type of Casing Specifications f ❑ Public ❑,Other ' 11 Delta Depth of Grout Seal f Type of Grout t ❑ Irrigation ___Approx Depth ❑ Eastern Surface Seal Installed by Repair Woik DoneType of Pump H.P. State Work Done Well-Destruction.",❑ Well Diameter Sealing Material (top 50') r '' Depth ` Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is r r-"",1 ravailable within 200 feet.) Installationwuill serve: r R idence Commercial Other , Number of living,units:'77 Number of b rooms Character of soil to a de�pt�h hof 3 feet:? r_"8" Water table depth SEPTIC TANK ❑ Type/Mfg'' Capacityf� No. Compartments 2_ PKG. TREATMENT.PLT. ❑ ' t ��I I Method of Disposal ti Distance to nearest- Well a� Foundation F Property Line LEACHING LINE 1!I No. & Length of lines -y Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 40 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 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 followi • "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 Ca' rnia" The.applican mu ail for all req d in ompiete drawing-on reverse's' e. _. Signed Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by ILI CA LTZ � Date tn"'"�"`p� Area Pit or Grout Inspection by --N., ,r'I �n-nAte I U-12-S Final Inspection by Date . - dditional Comments: Stk 466-6781 ❑ Lodi 389-3621 ❑ 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 CK FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE �PPEF1mrr'N0. +EH 13-24(REV,10183) C' LiJ`' 1 JOS 7 TM EH 14-26 v 1