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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT i 1601 E. HAZELTON AVE., STOCKTON, CA i Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i (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 City vy Lot Siz PM Ile Owner's Nam Address AN 7, 32E- MPhone Contract Address 9992X &Z License No., 7-6 Phony TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR C7 OTHER ❑ DISTANCE TO NEA REST:rSEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS I 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 ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I I irrigation t _.-Approx. Depth I I-Eastern Surface Seal Installed by i Repair Work Done ❑ Type of Pump ` f ,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 f I DESTRUCTION i I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence ZCommercial_ ther Number of living units: Number of r oms f Character of soil to a depth of 3 feet: _ Wa er table depthee SEPTIC TANK Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ / f Method of�7D�isp9sal Distance to nearest: Well Foundation Property Line�l f LEACHING LINE No. &Length of lines 6 Total length/size ' FILTER BED ❑ Distance to nearest: Well�iO Foundation Property Line SEEPAGE PITS Depth Size ,Number��J ! SUMPS ❑ Distance to nearest: Well " Foundation /4! Prope-ity Line DISPOSAL PONDS ❑ l 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: '9 certify that in the Orformanee W the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." � ;; �� # The applicant call for all r q "ed i ctions . Complete drawing on reverse std r SignedTitle: Date: r FOR DEPARTMENT USE ONLY / Application Accepte by _ Date 1 CSS 11q Area Pit or Grout Inspection by Dw -.Final Inspection by T Date 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, Silt_ CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK 4 CASH RECEIVED BY DATE PERMII'NO. INFO t"t:H 13.24(REV.1/8 5) —7, ' B {/ EH 14-28 /