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APPLICATION FOR PERMIT i° SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone 12091 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. qn City Lot Size PM r Job Address Owner's Name "�" ` Address Phone TAAC Contractor's Name License No. Phone I TYPE OF WELL/PUMP: I! NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTE�M REPAIR �-. OTHER ❑ DISTANCE TO NEAREST: SEIpTIC TANK SEWER LINES-f a t DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS LJ Industrial E] Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ADomesticlPrivate ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation —Approx. Dept `❑ Eastern Surface Seal Installed by ! i 1� State Work Done S Repair Work Done 9 Type of Pump H.P. Well Destruction ❑ Well Diameter ll Sealing Material (top 501 Depth -51 / Filler Material (Below 501 C/ TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial _ Other L Number of living units: 11 Number of bedrooms Character of soil to a depth)of 3 feet: Water table depth q" yr SEPTIC TANK _❑ IType/Mfg _Capadty No. Cam P partments PKG. TREATMENT PLT. El ' : € Method of Disposal ! 6 '4 ,` - -- -^- "`•"'^ Distance to nearest:.-. Well Fouhdation L' `----Property Property tine-- - '1 LEACHING LINE ❑ No. & Length of lines r Total length/size r ,. FILTER BED ❑ :I Distance to nearest: Well Foundation i %:r.!. }Property Line SEEPAGE PITS F-1 Depth Size ` + t Number SUMPS ❑ 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 laws, and rules and regulations of the San Joaquin Local Health District. ` Home owner or licensed ageA'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 Anner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following:"I cert rfy 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." �]I The applicant st ca 1 for all re it in ctions. Complete drawing on re rse side. I� e Signed Title: Ge ' Date: " FOR DEPARTM T USE ONLY Application Accepted by - �� Date Area ®� Pit or Grout Inspection by I Date Final Inspection by Date �b Additional Comments: Alli ❑ Stk 466-6781 . ❑ Lodi 369-3621 - ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies)to: Environmental Health Permit/Services 16D1 E. Hazelton Ave., P.O. Box 2009, Stk., CA.95201 • I FEE AMbUNT DUE AMOUNT REMITTEDASH RECEIVED BY DATE PERMIT NO. INFO + EH 13-24(REV.10/83) 315 - EH 14.26 - ^=J i'