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APPLICATION FOR PERMIT I SAN JOAQUIN LOCAL HEALTH DISTRICT ? 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 District. Job Address '71 �✓ Cit �r Lot Size / PM Owner's Name Address d{ " Phoney j �� Address ?a 7 _ PhoneContracto, �& _ License No.3 _ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES OSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE: OF WELL PROBLEM AREA CONSTA6-CTION SPECIFICATIONS ❑ Industrial ❑ Open,Bottom CD Manteca ia. of Well Excavation Dia. of Well Casing 171 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1-1 Public ❑ Other 1-1 a Depth of Grout Seal - - Type of Grout I I Irrigation __.Apprbx. Depth I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Sealing Material Itop 50') D Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ILZ REPAIRJADDITION l 1 DESTRUCTION I I INo septic system-permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: L Number of bedrooms 1_—!__ Character of soil to a dept of 3 feet: Water,table depth `s SEPTIC TANK Type/Mfg Capacity _N' _Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation � /�` Properly Line LEACHING LINE No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well �°�� Foundation /C � Property Line 5� � i —SEEPAGE PITS l A-�_Deptlh Size �f s, Number 21 SUMPS ❑ Distance to nearest: Well 1924. _ Foundation 10 __ 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 no 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 or all required inspections. Complete drawing on reverse side. ` Signed X Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by C6 Tk Date Area Pit Grout Inspection by to r Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 0 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 IFEEO AMOUNT DUE AMOUNT REMITTED CK 9 CASH RECEIVED BY DATE PERMIT NO. +.EH 13.24(FtEv.1/R 5) EH 14-26 -1 �-