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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 instail 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 a*hd the Rules and Regulations of the San Joaquin Laval Health District. ,q r Z. 10 /"�/�/J/ Job Address - City Lot Size 1 _ Plyt �j Owner's Name ' " Z- Address A Phone l �&&d ✓Contractor s_12 License No. �` ` Phone TYPE. OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION CI _ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 0 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES :DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS p [ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS !� ❑ Industrial ❑ Open Bottom ❑ Manteca pia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel,Pack ❑ Tracy Type of Casing Specifications F © Public ❑ Other ❑ Delta Depth of:Grout Seal Type of Grout ❑ irrigation ---Approx. Depth Cl Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump, H,P. State Work Done C Well Destruction ❑ Well Diameter Sealing Material (top 50) Depth Filler Material Met o i TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION C7 (No septic system permitted if public sewer is 4 - s available within 200 feet.) r Installation will serve: Residence_ Commercial_ Oth Number of living units: Number of om Character of soil to a depth of 3 feet: Water table depth i- SEPTIC TANK Type/Mfg ic2iCapacity No. Compartments PKG. TREATMENT PLT, ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE I�No. & Length of lines Total length/size s FILTER BED ❑ Distance to nearest: Well Foundation 42 7 Property Line r- SEEPAGE PITS EI Depth 2 ) Size "� Number SUMPS ❑ Distance to nearest: well .v r Foundation �^ Prope;w 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, 1 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 applican must tali f all require inspections. Complete drawing on reverse side. Signed Title: Date: fVt FOR DEPARTMENT USE ONLY Application Accepted by \J1��"' Date � �3� Areay Pit or Grout Inspection boate� � Final Inspection by Dat��y) 4 . Ad itional Comments: tk 466-6761 ❑ Lodi 369.3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 p licant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT RTED EMITCK 177INFO -,CASH RECEIVED BY DATE PERMIT N0. �d +EH13-24 4 ev.i i a sl �� r 23 EH 1428