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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) all the work herein . This cation is Application is hereby made to the SanCJooU4ui O�dinalncla No.549 for sewage or ealth District for a permitNo. 1862 for construct and/or end the Rules and Regulations of the San Joaquin made in compliance with San Joaquind County " Local Health District. y+ `?�Q Qr<+1 1<e �v City AC9ek7'0�'1 Lot Size 70 X 0 PM .fob Address Rv Phone Owner's Name �r � its kl Address i i f Address License No. Phone_. Contractor TYPE OF WELL/PUMP: NEW WELL LJ REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 11 OTHER ❑ SEWER LINES DISTANCE TO NEAREST: SEPTIC TANK �_� DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS -- �� Dia, of Well Casing ❑ Industrial ❑ Open Bottom ❑ Manteca Y Dia. of Well Excavation rType of Casing Specifications LlDomesticlPrivate- ❑ Gravel Pack ❑ Tracy ['1 Public F1 Other It ❑ Delta Depth of Grout Seal Type of Grout - i I I Irrigation �..Approx. Depth i I Eastern Surface Seal Installed by '" H P State Work Done Repair Work Done [A Type of Pump Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 Depth I Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION I I w-DESTRUCTION (No septic system permitted if public,sewer is, k Y s vailable within 200 feet.) R�Installation will serve: Residence! Commercial' ` Other L Number of living units: Number of bedrooms Water table depth Character of soil to a depth of 3 feet: w Capacity No. Compartments SEPTIC TANK ❑ Type/Mfg Method of Disposal PKG. TREATMENT PLT. ❑ ,,, Distanc a to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines` Total length/size { ft FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I') Depth Siza Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ , San Joaquin county ordinances, state laws, and t I hereby certify that I have prepared this application and that the work will be done in accordance with 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." Contractors 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 applica t must call for all required inspections. Complete drawing on reverse side. I 1 / Title: — �P.�.��PJt� — Date: Z. Signed " FOR DEPARTMENT USE ONLY - - f}ate — Area- Applicatio_noAccepted by; _ - _6 Date Final Inspection by Date Pit or Grout Inspection by Additional Comments ) F r 835-6385 ❑ Stk 466-6781 11 Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy Applicant " Return all-copies_to: Environmental-Health_P-ermitl Services-1601_E._Hazelton-Ave P,O.-Box-2009;Stk-CA-95201 — j/1 CK RECEIVED BY DATE PERMIT NO. k IFEE NFO AMOUNT DUE AMOUNT REMITTED ASH. .. + EH 1324(REV.1i145)' �� ,3 " €� EH 14-2e