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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT i 1601 E. i IAZELTON AVE„ 5TOCKTON, CA �iGi Telephone (209! 466-6781 [ PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (Complete in Triplicate) • I! Application is hereby made to the San Joaquin local Health District for a permit to construct and/or install the work herein described. Toss application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rul aRe ns of the San Joaquin Local Health District. Etio Job Address Cit Lot Size IPM Owner's Name t Address Php t y / i j//_ Contracto AddressLicens �P&i 1 TYPE ELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ it PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER'❑ DISTANCE-TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL Or INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTIO CATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia ell Excavation Dia. of Well Casing: ❑ Domestic/Private LlGravel Pack fl Tracy Type of Casing Specifications i� M Public F1 Other elta Depth of Grout Seal Type of Grout I I Irrigation epth I 1 Eastern Surface Seal Installed by — i Repair Work Done ype of Pump H.P. State Work Done Well Des n ❑ Well Diameter Sealing Material (top 50') ,I Depth Filler Materiil (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION i.l REPAIR/ADDITION l I DESTRUCTI0,NNNo septic system permitted if public sewer is vailable within 200 feet.) l' Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms i Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments I II � PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property line ; LEACHING LINE ❑. No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Weil Foundation Property Line SEEPAGE PITS I'] Depth Size Number ! SUMPS Ll Distance to nearest: Well Foundation 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. o Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this_permR 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,1 shall employ persons subject to worki"an's compensa- tion laws of California." The applicant Ist call for all require ' s ctlons. Complete drawing on re rse side. I Signe Title: ��C '. Date: F DEi . " PARTMENT USE ONLY Application Accepted by 4, tzz� Date Area Pit or Grout Inspection by Date Final Inspection by Date P� Additions! Comments: ElStk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 LlTracy 835-6385 F'•' { Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 II 'i �i IF E AMOUNT DUE AMOUNT REMITTED /��A H RECEIVED BY DATE /PIE{RRMIT'NO. t.EH 13-24{REV.iin51 EH 1429