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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. 4,4f GC��`,,r� Job Address �' ✓''� s J City Lot Size PM Owner's Name � Address ;'%`'�- Phone fddressContractor `� J1 License No. 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 ., FI Public (-1 Other Cl Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth I I 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 _ �f TYPE OF SEPTIC WORK: NEW INSTALLATION )>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 y�Other Q Number of living units: Number of bedrooms _� C Character of soil to a depth of 3 feet: JAL ff� Water table depth r �. SEPTIC TANK ❑ Type/Mfg Capacity__4.�- No. Compartments PKG. TREATMENT PLT. ❑ I Method of Disposal Distance to nearest: Well Foundation Property Line F• W LEACHING LINE ❑ No. & Length of lines Total length/size Cf FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS AfDepth Size _ Number SUMPS ❑ Distance to nearest: Well *'�f Foundation Property Line DISPOSAL PONDS ❑ 1 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 must call forallrequired inspections. Complete drawing on rever a side. Signed X Title: ��f'�� Date: -7 '- A O FOR DEPARTMENT USE ONLY Application Accepted by J� � `--✓ Date Pit Grout Inspection by Lz(3ete // r Final Inspection by --Bate 2 S Additional Comments: ❑ 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 FEE INFO AMOUNT DUE AMOUNT�/��Ry/E�MITTED CASH RECEIVED BY DATE �[PPERMIT NO. EH 13- .�in51 ./,V 0 W EH It-2t1 V!