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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL F EATH DISTRICT 1601 E. HAZK I ON A , 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 " `' "-- — City Lot Size or•S!r ' — PM 72,2 4 Owner's Name' g ' Address . �` Phone Contractor's Name �- License No. ' �7 r Phone3 _3 s TYPE OF WELL/PUMP: 'NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES T DISPOSAL FLD. PROP. LINE i 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 ❑ Tracy.', Type of Casing ZSpecifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal; Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work=Done [IType of Pump H.P. State Work Done f' Well Destruction k ❑ Well Diameter Sealing Material (top 581 Depth Filler Material (Below 501 ' TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ iNo septic system permitted if public sewer is I } . available within 200 feet.) Installation will serve: Residence r`Commercial Other t Number of living units:__L_ Number ofbporooms J oe Character of soil to a depth of 3 feet: Water table depth Gp 0 No. Compartments SEPTIC TANK L'�Type/Mfg g �` � �- apacity� +� PKG. TREATMENT PLT. ❑ 5-`s Method of osal i Distance to nearest: Well�� 3 Foundation ._-Property Line LEACHING LINE IT- No. & Length of lines 3 ' I Total length/size FILTER BED I ❑ Distance to nearest: Well h Foundation Property Line 's V SEEPAGE PITS ; Depth r Size �'� Number .3 SUMPS C3 .Distance to nearest: Well�.�� Foundation L� Property Line V DISPOSAL PONDSS ❑ 4 I 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquiri�county ordinances, state laws, and I rules and regulations of the San Joaquin Local Health District. I it 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." ! r c The applicant must call f all required inspections. Complete drawing on reverse`side. Signed ; --.Title:,_6 ioj[ -. Date: cs I FOR DEPARTMENT USE'ONLY / Application Accepted by Data Area Ot' r Grout Inspection by- Dater Final Inspection by ate Additional Comments: 666 t ❑ Stk 466-6781 1,,❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8355-6385 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 CASH --y ^7 l + EH 1324IREv.10le3i -7� �� r g(p <�vi / `� l EH 1426 '�••