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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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. 1962 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address d City` of Size PM Owner's Nameddress f� ® Phone Cv Contractor's Name License No.. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT El 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 USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Q Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack E Tracy 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 Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION V REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is `), available within 200 feet.) Installation will serve: Residence Commercial_ Other n Number of living units: Number of be ooms f0kle— 2 V } Character of soil to a dept "of 3 feet: m Water table depth= � SEPTIC TANK If Type/Mfg Capacity D No. Compartments x _ 1 PKG. TREATMENT PLT, ❑ Method of Disposal, - -" -Distance to nearest: Well Foundation Property Line Y '« LEACHING LINE No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well undation Property Line f SEEPAGE PITS IH�_Dspth Z`, Size J3 Number OP\_Jv� r ,1.J�,1.Jh, SUMPS ❑ Distance to nearest: Well Foundation t Property Line 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."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 must call for all required inspections. Complete drawing on reverse side. ~ l Titls:�� .Signed Dae: FOR DEPARTMENT USE ONLY Application Accepted by Date J `� Area Pit or Grout Inspection by Date 0 Final Inspaction by _ Date4 i 491 Additional Comments: b Cvw =7 15-Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 82.3-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., C 95201 FEE INFO 1 AMOUNT DUE AMOUNT REMITTED CCAKSH RECEIVED BY DATE PERMIT"NO. +EH 1324(R EV.141631 P f q O �;f - , 6 -7 EK y '7 EK 1428 `"�1 �1�J `y }