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APPLICATION FOR PERMIT \` € SAN"JOAQUIN'LOCAL HEALTH DISTRICT 7601 E. HAZELTON AVE., STOCKTON, CA - Telephone (209) 466-6781 - " v PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 4� J ;-i. " 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 Ryles and Regulations of the San Joaquin Local Health District. - �E '` City ��i '�i of Size PM Job Address Address Owner's Name = .. ._ .....-.. _ Phone Address A icense No. Phone 9'3 Contractor f TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ O ' PUMP INSTALLATION /1,)3 if/i.� YSTEM REPAIR f�' __ _ _ OTHER ❑ WITX. Cc'yj � f,'1 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 i ❑ industrial El Open Bottom LJManteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack El Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depte[�.tl? Surface Seal Installed by 6 IIJ Repair Work Done ❑ Type of Pump S P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 6 Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ aNailableo septic systemithin rented if public sewer is Installation will serve: Residence— Commercial— Other Number of living units: Number of bedrooms x Water table depth Character of soil to a depth of 3 feet: SEPTIC TANK A_._ 1117 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal ►' Distance to nearest: Well Foundation Property Line 9 3 a LEACHING LINE "❑' No. & Length of lines Total length/size FILTER BED '❑ Distance to nearest ..Well Foundation Property Line k `� ..... ... SEEPAGE PITS ❑ Depth —4 ,Size s 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 aecord"arlce wlth-San Joaquin county ordinandes, state laws, and rules and regulations of the San Joaquin Local Health District. I, 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 manneras,to become subject to workman's compensation laws of California."Contractors hiring or sub-c ntrac`ting signature certifies the following:"I certify that in the"performance of the work for whi— this perm`iYis issued,I s II employ persons subject to'workman's compensa tion laws of California."� " The applicant myst f all rr inspections. Complete drawing on reverses e. k r a Title: _ Date: FOR DEPARTMENT USE ONLY r �� .. O �S Area � Z - Application Accepted by Date e7 Pit or Grout inspection by " Date Final Inspec#ion by Date — Af- imme �. ` Additonal Conts: }��--J• �� ❑ St4&6 6781 El 369-3621 ❑ Manteca 823-7144 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95241 .. FEE CK RECEIVED BY DATE PERMIT"NO. INFO y AMOUNT DUE. AMOUNT REMITTED CASH ` +EH 13-241REV.1/85) 5 �� ss5 -7S�- .� . EH 1428 ,•,...,.. _"".