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i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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 inlcompliance 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 �rz �y !- {� City / �t .d+f Lot Size PM Owner'I Name Address Phone Contra�tor;f Ii�� (y �_y Address z �' � � License No l�C5 Phone :i TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ II PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 1� FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED US`E- TYPE OF WELL f'fTOBLEM AREA CONSTRUCTION SFECiF1CATlONS"`• ❑ Induistrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I f`l Public s ❑ Other (-] Delta Depth of Grout Seal Type of Grout I I irrigation --Approx. Depth I 1 Eastern Surface Seal Installed by '1u Repair Work Done ❑ Type of Pump H.P. State Work Done C Well Destruction` El Well Diameter Sealing Material (top 50') R Depth Filler Material (Below 50'1 TYPE OF SEPTIC WORK:- NEW INSTALLATION 11 REPAIR/ADDITIONX DESTRUCTION I I (No septic system permitted if public sewer is '—N available,within 200 feet.) Installation will.serve:%` Res"idenceCommercial_ Other Number of living units-. V Number of bedrooms W t Character of soil to a dipth of 3 feet: ' - Water table depth SEPTIC:TANK ".� O Type/Mfg _ Capacity No. Compartments ei PKG. TREATMENT PLT`0 .rte Method of Disposal 4V Distance to nearest: w e11 �� Foundation Property Line I / Y LEACHING LINE F No. & Length of lines p" Tota! length/size FILTER!�.ED ° ❑ Distance to_nearest: Well Foundation Property Line ! �� r ' M .�_ SEEPAGE PITS "1"1 Depth ti , Size Number 4 416 - . .� SUMPSy L 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 taws, and k rules and regulations of the San Joaquin Local Health Diltrict. 11 ` 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 i emploAi ny 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." The applicant must calf for all r quired - spections. Complete drawing on reverse side. it I Signed X_ Title: Date: �� # FOR DEPARTMENTU ONLY y Application Accepted by y Area Pit or Grout Inspection by _ Date Final Inspection by Date f Additional Comments: ❑ Sik��466-6781 ❑ Lodi 369-3621 C1 Manteca 823-7104 El Tracy 835-6385 Applicarit - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I T FEE v _ . INFO- AMOUNTTT IDUE AMOUNT REMED �� VCK ^,RECEIVEDBy DRAT+}E[��/ PERMIIT'N6._ +^-EH 13-24[REV:f 19 5] ! - W11r `(Jro n•.• EH N-26 11