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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE LTON•.AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 7 YEAR FROM DATE ISSUED tl�,� �+• (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_ a +� Job Address ' ` r City ! Lot Size XAC f PM �Sl /a A _ Owner's Name Address Phone �( Contract, Address License No T7Y Phone �_ TYPE OF WELL/PUMP: NEW WELLQ, WELL REPLACEMENT ❑ DESTRUCTION' \� PUMP INSTALLATION ❑ 'SYSTEM REPAIR ❑ OTHER ❑ V DISTANCE TO NEAREST: SEPTIC TANK SEWE S DISPOSAL FLD. ROP�LINE FOUNDATION AGRICULTURE OT LL PITS/ INTENDED USE TYPE OF WELL PROBLEM AREA CONST CIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca a. of Well Excavation Dia. of Well Casing 11 Domestic/Private ❑ Gravel Pack ElTra Type of Casing Specifications ❑ Puhflc' -Other"""'°"" " Delta-----.-.,-.,,..Depth,of-Grout-Seal Type of Grout ' a ❑ Irrigation _-Appro epth EJEastern Surface Seal Installed by Repair Work Done El Typeump - H.P. State Work Done_ Well Destruction ❑ ell Diameter Sealing Material {top 50'} Depth Filler Material {Below 501 y TYPE OF SEPTIC WORK:- NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTfON (No septic system permitted if public sewer is OFIN available within 200 feet.) a Installation will serve: Residence_ Commercial_ Other s' Number,of-living units: _Number of bedroomsy Character of soil to a depth of 3 feet: } Watertable depth 1 SEPTIC TANK ❑ T e/Mf # 3YP 9 - Capacity No. Compartments w-�.- PKG. TREATMENT PLT. ❑ Method of.Disposal V F ." Distance,to.nearest: Well Foundation '- Property Ling LEACHING-LINE,^ ❑ 'No. &rLength.of lines '"`�� Total length/siie ' #. FILTER BED ❑ Distance'to nearest: Well Foundation's Property Line I 9 7 SEEPAGE PITS ❑ #Depth'" Number SUMPS C1 Distance to nearest: Well -PropertyFoundation Line- DISPOSAL�NDS ❑ . G' ;• t '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 Joaquiri;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 F -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 m t all for all required spections ompfete-drawing on,reverse side._ r� Signed Title: Date: R DEP"TMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspectio by' Date Final Inspection by Date 1 { Additional Comments: Y� '��'�"�"� '�"t,rc3 4&e1(t S ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ AaAteca 823-7104 ❑ Tracy 835-6385 Cf+-t,, 0+: Ori"r-4(vey��` Applicant- Return all copies to: Environm}ental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. EH 13-24(REV.t/135) 0 UC) V �� EH 14.28