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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 hereby made to the San Joaquin Local Health District for a permit to construct andlor 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 Art 00 LX) City Lot Size2ffi PM Owner's Name Address( Phone " t Contractor Address �. �/ _ License No. Phone TYPE OF 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 PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ industrial ❑ Open Bottom ❑ Manteca' Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack L1 Tracy,,,,, Type of Casing Specifications FI Public Ll Other— T Cl Delta -i-- Depth of Grout Seal Type of Grout ---- I ] Irrigation --Approx.f Depth l I Eastern Surface Seal Installed by _ } Repair Work Done ❑ Type of Pump - H.P. State Work Done Wel! Destruction ❑ Well Diameter Sealing Material (top 50') _T Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: ResidenceX Commercial Other Number of living units: —1L Number of bedrooms 4 t Character of soil to a depth of 3 feet: ° Water table depth SEPTIC TANK Type/Mfg -FnCapacity ICOt No. Compartments -� PKG. TREATMENT PLT. ❑ t Method of Disposal'~ I Distance to neatest:} Well Foundation V Property Line LEACHING LINE X No. & Length of lines Total length/size r FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS X Depth Size Number SUMPS Cl Distance to nearest: Well Foundation Property No 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 Di$trict. 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 ifornia." The applic nt ust call fo a requi inspections. Complete drawin averse side. �f Signed Title-] Date: i FOR DEPARTMENT USE ONLY `y Application Accepted by Data -s-- v Area Pit or Grout Inspection by Date Final Inspection by5Z Date r ; Additional Comments: ❑ Stk 466-6781 ❑ Lodi -3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 'Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTEDHNRECEIVED BY DATE PERMIT'NO. INFO [� �/�. +.EHS3-241REV.I/85) I r+ �� 17- 3 �� 'i� �� EH 14-28 + I . S 1 I