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F APPLICATION FOR PERMIT .-, SAN JOAQUIN LOCAL HEALTH DISTRICT ' 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED f (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 Di/ ct. stri �� , Jab Address r 3 q'I f Y• �` City f� Lot Size PM Owner's Name Address �-r c� Phone Contract Address ! 4r� License No.- 23 Jai Phone '5125- TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM[AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seat Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seat Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 4' Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 57 REPAIR/ADDITION ❑ DESTRUCTION ❑ Mo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial— Other Number of living units:--L- Number ofdrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK �TypelMf i�z� 9 Capacity Qd No. Compartments PKG, TREATMENT PLT. ❑ r t Method of Disposal Distance to nearest: Well /00 Foundation�� Property Line LEACHING LINE Q�No. & Length of lines Total length/sizelao FILTER BED ❑ Distance to nearest: Well /400 ' Foundation _ 46' Property Line 1 SEEPAGE PITS U?�Depth Size Number t + SUMPS ❑ Distance to nearest: Well fbfl, Foundation Property Line DISPOSAL PONDS ❑ 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 F-4" . 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 manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature a 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 a eq 'red inspections. Complete drawing on reverse�V. y'*de. - F Signed Title: . _ Date: 7 Oct !1 p(!3 ! _ -# FOR DEPARTMENT USE ONLY Application Accepted by Date v j Area,0 f 4, Pit or Grout Inspection byDate D Final Inspection by Date &L�Z V\./ Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 P Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT"NO. + EH 13-24(REV.t/s 5) EN 14-28 O Ly �/