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APPLICATION FOR PERMIT r SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA Telephone 12091 466-6781 PERMIT EXPIRES 'I'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 l Local Health District. I rob Address ' v y1 d `� �CJ City �W Lot Size C PM jOwner's NamAddress IdA Phone 36 Contractor_V v� #6e, Address License No, Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INS;ALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 ExcavationDia. of Wel) Casing El Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑.Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation _._Approxi Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 1 TYPE OF SEPTIC WORK:, NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is 1 available within 200 feet.) Installation will serve: Residence Commercial_ Other6� Number of living units: Nume o erooms her dy Character of soil to a depth of 3 feet: Water table depth i. SEPTIC TANK X Type/Mfg J [ tT �1? Capacity No. Compartments PKG. TREATMENT PLT. ❑ _E Method of Deis 131 Distance to nearest: Wel/ Foundati ...-.....-. Property Line { Lit LEACHING LINE No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Wel Foundation�..-_ Property Line2081 SEEPAGE PITS I 1 Depth l Size Number , SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I 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, an 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 taws of California."Contractors hiring or sub-contracting signature �y 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- f i tion laws of Cali ia." The applicant u call all re u'ed inspections. Complete drawing on raver side. Signed X Title: �� FOR DEPARTMENT USE ONLY 'j f Application Acceptedby Date 2 / Area r ! j�/ Pit or Grout inspectio �_J Date Final Inspection b ��''Date � f 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 i FEE AMOUNT DUE 1 AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO k + EH13-24(REV-i / ¢ EH t4-2ti ,..rE. k At4W +