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i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is'heteby 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 CK_ City Lot Size PM s Owner's NameAddress Phone / J Contracto Address i7^ License No/ Phone TYPE OF WE L!P M : 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 PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing El Domestic/Private ❑ Gravel Pack �❑ Tracy'W Type of Casing Specifications - FI Public F Other F1 Delta Depth of Grout Seal Type of Grout—.— I rout I I Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by - Repair-Work'Done ❑ Type of Pump H.P. State Work Done i Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION M REPAIR/ADDITION l 1 DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence _L Commercial_ Other Number of living units: _J__ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Q Type/Mfg 7r, Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well 16 O Foundation -.' _._.._.— Property Line 1___4 LEACHING LINE ❑ No. & Length of lines !` Total length/size ' FILTER BED ❑ Distance to nearest: Well_4_0_ Foundation . i�2 Property Line SEEPAGE PITS 11 DepthA X-r(2XI19 Size — Number ff S L-1 Distance to nearest: Well-� Foundation Property LineSAL PONDS ❑ 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. 1 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." The applicant must call for all red inspections.Co late drawing on reverse side. Signed X Title: Date: FOR DEPARTMENT USE ONLY l Ap ca ion Accept d by ^ 4Date �—QQa_ Area i 3 rout In ction by Date Final Inspection by'-T- Date�• '-rf 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 AMOUNT REMITTED CK RECEIVED By DATE " PERMIT NO. INFO ' I �{(�� CASH a EH 13-24(REV.1/851 i l Uv EH 14-28 111