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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT l Q9- p 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone {209) 466-6781 . PERMIT EXPIRES 11 .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. 1851 for well/pump and the Rules and Regulations of the San Joaquin LAdd t.- -,; .., ��. city 't\��! Lot-Size PIM lli -1- y SlAryl� Address PhoneAddressLicense No. Phone IUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ k3i 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 i ° Dia. of Well Casing E-1 Domestic/Private ❑ Gravel Pack ElTracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ irrigation _--Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of PumpW.P. State Work Done Well Destruction ❑ , Well Diameter l iSealing Material (top 501 a,Depth` t l Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION Ll "REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.) 1 . rps Installation will serve: Residencer Commercial Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet:1 Water table depth SEPTIC TANK Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line I LEACHING LINE C1 No. & Le�gth of lines Total length/size FILTER BED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS El Distance+to to Well Foundation Property Line DISPOSAL PONDS ❑ ! t 1 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 6 ` 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, l 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 per is issued,I shall employ persons subject to workman's compensa- tion laws of California." The applicant call for all required#nspactiofns C rpte vveverse sir> Q Signed ` Title: r' Data: — FOR DEPARTMENT USE ONLY $ _ n Application Accepted b j Date t Are 1 ate Final Inspection by e Pit or Grout Inspecti ,r�, Additional Comments: v I() S erns( 1114-7 ❑ Stk 466-6781 ❑ Lodi 369-3511 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazekon Ave., P.O. Box 2009, Stk., CA 95201 I FEE AMOUNT DU' AMOUNT REMITTED RECEIVED BY DATE PERMIT"NO. INFO �� • + EH 13-24(REV.F/95) 1 F. EH 1428 :