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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1641 E. HAZELTON AVE., STOCKTON, CA Telephone (249) 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 I 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. I Job Address _. 7 9" /` City = a Lot Size � 3;. PM Owner's Name Address Phone I J� Contractor's Name License No. 7 Phone ' 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 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 E ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation —Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work pone ❑ Type of Pump H.P. State Work Done \ Well Destruction ❑ Well Diameter Sealing Material (top 501 . Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (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 Character of soil to a depth of 3 feet: ./4 ? Water table depth SEPTIC TANK C} Type/Mfg L art Capacity /,c p ty No.i.Campartments 7.— PKG, TREATMENT PLT. ❑ pr "� y ✓I Method of Disposal Distance to nearest: Well Foundation It, Property Line 01 LEACHING LINE 2 No. & Length of lines _ Total length/size �% FILTER BED ❑. Distance to nearest: Well l -C%/ oundation . t� Property Line SEEPAGE PITS E�-�' Depth _>�' S' Size Z J Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 17 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 Signa re 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 a t become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following:"I certify that he 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 m c fo I r rnspecti s. plete dr wing on reverse side. `� Signed tle: r.�� t' �T Date: �� �OR DEPARTMENT USE ONLY Application Accepted by ADate �� / Area 0/ it or rout Inspection by t ate Final Inspection by Date Additional Comments: ❑ Stk 466-6781 Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6386 Applicant- Return al copies to>Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK# RECEIVED BY DATE PEAMiT N0. INFO CASH 15H;¢ (REV. 1e,1131 �