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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT j 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 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 Dishsttrir'iicjtt..j/ [1 Pi ,yJ Job Address t City b�"v r4AJ Lot Size Q pnr� 6'T�ck Tati� Owner's Name _ Address - Phone Contractor's Name / 1, ense No. � 'S Phone S o1JA—Q'0 X [ TYPE OF WELL/PUMP:' NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USEr� TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack T, fl Tracy Type of Casing Specifications ❑ Public ❑ Other : ❑ Delta Depth of Grout Seal Type of Grout -.> ❑ Irrigation Approx. Depth ❑ Eastern Surface Seal Installed by da Repair Work Done I❑ Type of Pump H.P. State Work Done b� Well Destruction ❑ Well Diameter +Sealing Material atop 50,1 Depth Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is ' 'available wit in 200 feet.] Installation will serve: Residence Commercial_ Otherr�Eef Z. Number of living units: Number,of bedrooms f Character of soil to a depth of 3 feet( 4W 0-4 Water table depth SEPTIC TANK Type%Mfg " Capacity No. Compartments PKG. TREATMENT PLT. ❑ -" "' Method of Disposal 1 ! CO Distance to nearest: Well Foundation_.�_ Property Line �� LEACHING LINE � No. & Length of lines �� .-Trot/al length/size FILTER BED Ll Distance to nearest: W 11 (0 Foundation 4' Property Line P-� SEEPAGE PITS , Depth a .� l Size 7 3 lrA't Number J SUMPS ❑ Distance to nearest: Well 4140 Foundation f�. i Property Line 4:M 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 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 must c for all uired insV ctions. Complete drawing 9Q reverse side. r ' �`' / Signed Title: • ate: i AS FOR DEPARTMENT USE O LY Application Accepted by Date �`� _` Area b T PR or rout Inspection by to - Final Inspection by ate 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 FEEy INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. +EH 1426(REV.10183) ' \ t'7 O �.{ S. c? `{ �c— ` ✓/ "4 -!