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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE, STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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, (71 Oily WCity Lot Size PM Job Address `/ 64 2 _ 1 �,� Owner's Name �� t Address , PhoneG 4n7Phone Contractor dress License No.�" TYPE OF WELL/PUMP: OF NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION 1-1S STEM REPAIR OTHER 11 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. . PROP. LINE FOUNDATION AGRICULTURE LL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONS CTION SPECIFICATIONS El Industrial ❑ Open Bottom El Manteca Dia. ell Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Ty e of asing Specifications M Public Cl Other F- Delta epth o Grout Seal Type of Grout I I Irrigation Approx. Depth l I Eastern Surface eal Installed by - Repair Work Done ❑ Type of Pump H.P, State Work Done_ Well Destruction O Well Diameter Se rng Material (tp 50'1 Depth ler Material (Bel 50') Q TYPE OF SEPTIC WORK: NEW INSTALL TION PT REPAIRIADDITION l I DESTRUCTION { I (No septic system permitted if public sewer is \r. v table ithin 200 feet.i V� Installation will serve: Residence_ Commercial Other. 0 *f R � Number of living units: Number of bedrooms L% ,%/ e � Character of soil to a depth of�feet: Water table depth SEPTIC TANK ❑ Type/Mfg— Capacitj� 1 — No. Compartments PKG. TREATMENT PLT. ❑ {�I �V Method of Dispos Distance to nearest: Well (S0 4 F ndat n �_k Property Line -- T LEACHING LINE ❑ No. & Length of lines T tel length/size 0 FILTER BED ❑ Distance to nearest: Well 4 Foundationi� Property Line F SEEPAGE PITS I I Depth Size Number c^ SUMPS L) Distance to nee st: Weil Foundation--C- Property Line41 J DISPOSAL PONDS El hereby certify that I have prepared this application and that the woAx 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 agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 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:pplicant m7t call for all re ' d inspectio s. Complete drawing on reverse side. t_,� t d X A Title: Date: / FOR DEPARTMENT USE ONLY Application Accepted by • Date �' D Area Pit or Grout Inspection by Data Final Inspection by Date f 1 d 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. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMITNO. INFO ` CASH { +.EH 13.24(REV.r I H 5) r S t"'t,p O �7 y y"- 1,,O C 1 EH 14-26 1 L i