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APPLICATION FOR PERMIT 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. �/ w^, Job Address 7 / Q �^ �/�� "/' /✓Cit of Sizl_1 t ` t Owner's Nam z ? �'1��"`�-� Phon� L� Address � —s� r Contractor — Address 15 � License T Y S 7 Phone— TYPE hone TYPE OF WELL/PUMP: NEW WELL 1�—_ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION 9;.— SYSTEM REPAIR ❑ OTHER ❑ _ DISTANCE TO NEAREST: SEPTIC TANKQ�i/ SEWER LINES DISPOSAL FLD. PROP. LINE �. FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS (f ❑ Industrial 9"6pen Bottom ❑ Manteca Dia. of Well Excavatio Dia. of Well Casing 44.1 Tfiestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f'1 Public 17 Other Ll Delta Depth of Grout Seal Type of out — Irrigation _Approx. Depth' l lI Eastern u-face Seal Installed by — - Repair Work Done ❑ Type of Pump_ c H.P, State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial Other Number of living units: Number of bedrooms C Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line r LEACHING LINE Ll No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Cl 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 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 applicant mu call for all required inspections._, omplete drawing on reverse side. Signed X Title: 4� � Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area 6� � - / Pit or Grout Inspecti by Oat tv1 t}—Final Inspection by Date Additional Comments: 'L Stk 466-6781 ❑ Lodi 369-3621 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 FEEAMOUNT DUE AMOUNT REMITTED K 4 RECEIVED BY DATE PERMIT NO. INFO EH 3-24 IR �-2 EH4-2e S Il