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✓/. APPLICATION FOR PERMIT ON JOAQUIN LOCAL HEALTH DISTFF* 1601 E. HAZELTON 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 rCounty Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. c City I _ ".' Lot Size "- PM Job Address Owner's Name Address - —_ Phone Contractor •' "- '1 -� -� Address - - - License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ lyl PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 13n I'f i2 DISPOSAL FLD. DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PROP. LINE ^ a� n FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS it ❑ Industrial ❑ Open Bottom Fr' Manteca Dia. of Well Excavation — Dia. of Well Casing Type of Casing � -,' -- ,p 7�Jl Specifications ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Tf ,:'1�„� Type of Grout=—OwC n Public _ n Other ❑ Delta Depth of Grout Seal = C^, 1 Irrigation =• --—Approx. Depth 1 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 -- �t f 0_'- Depth Filler Material 18elow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION t I DESTRUCTION I I (Nailabptic system m (emitted it public sewer isavle . Installation will serve: Residence_ Commercial_ Other Number of living units: _ Number of bedrooms Water table depth Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments Method of Disposal PKG. TREATMENT PLT.❑ Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ 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 ❑ I hereby certify that 1 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 Di1trict. 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 for all required inspections. Complete drawing on reverse side. Signed XTitle: Date: FOR DEPARTMENT USE ONLY / 'y1. Application Accepted by / / ( p Date �! '� / Area 13 Pit or Grout Inspection by ' Date L Final Inspection by t-'b Date �- Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8356385 Applicant- Return all 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 PERMIT NO. l INFO (CASH ♦.EH 12.24(REV.1/.51 -f?960 (J /� ' • " �l ��l ��_�C EH 14211