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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 7 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 __ G� �/ CCS _.,.._ Cit ACL t Lat Size City PM Owner's Name Address Phone S Contractor Address _License No Phon TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ - .._ ._._ . . _.PUMP,INSTALLATION ❑ _ SYSTEM REPAIR ❑ _ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ._T ! 41p15POSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL L OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation .-n--,Dia. of Well Casing �` r ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing ,Specifications M Public C1 Other ❑ Delta Depth of Grout Seal Type of Grout _ r t<" I I Irrigation —.Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State-Work Done_ r Well Destruction El Well Diameter Sealing Material (top'50') ' Depth Filler Materiaf(Beiow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION V, REPAIR/ADDITION f I DESTRUCTIONA I (No septic system permitted if public sewer is a available within 200.feet.) _ Installation.will_serve: Residence Commercial_ 'Other ' Number of living units: —V Number of bedrooms .-`� T. Character of soil to a depth of 3 feet: Water table depth : `SEPTIC TANK ❑ Type/Mfg i CapacityNo. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well.-_ Foundation 1 Property Line ��^ LEACHING LINE r No. & lines of Length g � Total length/size FILTER BED ❑ Distance to nearest: Well 04260= Foundation' g*J. __�TProperty Line >F-7_7— SEEPAGE PITS l I `Depth" Size 1rj u�ber ` SUMPS -Distance to nearest: -Wel! Foundatiofr - _ Property Line DISPOSAL PONDS r ❑ t I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinanc�s, state laws, and z rules and regulations of the San Joaquin Local Health District. 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 f requ' ed inspections. Complete drawing on reverse side. Signed X Title: 2. Date: _f zz R DEPARTMENT USE ONLY Application Accepted by 4, Date Area Pit or Grout Inspection by Date Final Inspection by Date ,' 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. Haz6lton Ave., P.O. Box 2009, Stk., CA 95201 wFSE AMOUNT�DUE- ._.._.AMOUNT REMITTED CK _. .._ RECEIVE DATE 'Pift O BY " AA1Y'NO-' INFO CASH + EH 13-24 4REV.1/to SI T " EH 14-2e 3��