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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON 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. Job Address .,/� '(� `�'..LCity Lot Size 7-6) q_�_P�m Owner's Name Address Phone Contractor's Name ense No. 4 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP,INSTALLATION ❑ SYSTEM REPAIR C OTHER ❑ 1 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 El 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 Seal Type of Grout ❑ Irrigation ----Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ 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 E (No septic system permitted if public sewer is d �rr-L available within 200 feet.) Q Installation will serve: Residence Commercial Other ✓Le''jL/�! Number of living units: Number of b drooms 2- C /?," 5 Character of soil to a depth of 3 feet: Water table depth 7t1, SEPTIC TANK ❑ Type/Mfgr L Capacity &!l 0 No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal V ' Distance to nearest: Well/oi� Foundation 1(/ Property Line LEACHING LINE : ❑ No. & Length of lines f D Total length/size FILTER BED ❑ Distance to nearest: Well Foundation_ �L_ Property Line e r SEEPAGE PITS ❑ Depth Size Number SUMPS ❑' 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. Home owner or licenseTagent°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 �for re Inspections. Co plete drawing on re rse sidSigned X _ Title: ( ?^— Date: FOR DEPARTMENT USE ONLY Application Accepted by _4 Date r1 'U Area Pit or Grout Inspection by Date Final Inspection by ° Date 22— O y Additional Comments: r ❑ 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 EE IF AMOUNT pUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO.