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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELLTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ✓I�+4 42 (Complete in Triplicate) Application is hereby made to the San Jocation is aquin Local Health District for a permit to co truct and/or insatraldl the RulesWork hnd hereindescribed. of the San rJoaquin made in compliance with San Joaquin County Ordinance No. 549 for s/ewage�or�No. 1 for el Ipyq+p 1 Local Health District. V rj � G fivQ Crty of Size PMad 011 ddress 1 Address r mbhone Owner's Name r �� r License No,—82 Contractz Phone ~�� ddress TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 11 OTHER El PUMP INSTALLATION 71 SYSTEM REPAIR LJOTHER El 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 Dia. of Well Casing f] Industrial ❑ Open Bottom ElManteca Dia. of Well Excavation 11 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f`r Public ❑ Other 5 Delta Depth of Grout Seal Type of Grout — I I irrigation --Approx. Depth ! I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth - Filler Material IBelow 501 m TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ! I DESTRUCTION I I (No septic systithinem rented it public sewer is Installation will serve: Residence Commercial__ Other o Number of living unim Number of" e ooms /�� Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Type/Mfg � Capacity No.Compartments PKG. TREATMENT PLT:'❑ f Method of Disposal ' � �}r� f � f Distance to nearest: WeEI S.� Foundation_�` :�Property Line ca LEACHING-LINE r No. R"Length of lines TotaE'length/size �X riLI /490'FILTER HED ❑- Distance to nearest: Well �=— Foundations_.— Property Line s. _ SEEPAGE PITS Depth Size Number fr f / SUMPS ;� 11 , Distance to nearest: Well (J Foundation_/4) Property Linei�.___ DISPOSAL_ PONDS,-' `0 r I hereby certify that I have prepared this appiication ind 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. fy that in the performance oft work for which this permit is issued, I shall not Home owner or licensed agent's signature certifies the-following: "I certi 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 ust call fo I re ired inspections. Complete drawing on reverse sid : Signed X f� Title: f Date: - FOR DEPARTMENT USE ONLY Application Accepted b� Data 6 Area it r Grout Inspection by Date( Final Inspection by Dates �� Additional Comments: L G ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 82377104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEEAMOUNT DUE AMOUNT REMITTED CASH RECEIVED By DATE PERMIT N/O. INFO j p B� ~fir +.EH13-241REV.t/n51 EH t4-2e