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APPLICATION FOR PERMIT / �•, SAN JOAQUIN LOCAL HEALTH DfSTRfCT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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. /' f 4Z-3, 54 ��(7/L~ City /� /�`�!j Lot Size PM Job Address Address Phone `f Owner's Name Contractor 7� Address License No. Phone 11 TYPE DF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing ❑ Industrial El Open Bottom ❑ Manteca Dia. of Well Excavation Type of Casing Specifications ❑ Domestic/Private d Gravel Pack ❑ Tracy yp g Type of Grout f`I Public ❑ Other ❑ Delta Depth of Grout Seal I I Irrigation —.Approx. Depth i I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H,P. State Work Done _ Well Destruction ❑ Well Diameter _ Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION (1 RFPAIRIADDITION ( I DESTRUCTION (No septic system permit7774 vailable within 200 feet. 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 SEPTIC TANK LI Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I i Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ d that the work will be dyne in accordance with San Joaquin county ordinances, state laws, and I hareby certify that I have prepared this application an 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 s of California." Contractors hiring or sub contracting signature employ any person in such manner as to become subject to workman's compensation law certifies the following: "I certify that in the parlor nca of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws Cali rnia." The app/cant all f all req ins C plate drawing on reverse side. .,� Signed X — Title: Date: FOR DEP RTiMENT USE ONLY ff Application Accepted by Da:�J� Pit or Grout Inspection by Data Final Inspection Dat Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 El 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 FiE7 AMOUNT DUE AMOUNT REMITTED CK QA RECEIVED BY DATE E;EIi'NO.INFO �7EH 13.2+t(FEV.i i n 5) Ar EH 14-2e --- L7