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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �. (Complete in Triplicate) Application is heoeby 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/�G/rr� ' C/ City Lot Size PM Job Address _-jc� Owner's Name /��AP 155^m1/�1 Y h Address �� Phone Contractor �t'S Address d �'� +^' �� License No. Phone NEW WELL WELL,REPLACEMENT ❑ �� -DESTRUCTION TYPE OF WELL/PUMP: q ' PUMP INSTALLATION'0'. ��- Sl(STEM REPAIRTL7� OTFiERT❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS + INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia of Well Casing ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Type of Casing Specifications � El Domestic/Private U Gravel Pac� ❑ Tracy Type of Grout -- f�i Other [ 1 Delta Depth of Grout Seal ['1 Public Depth 1 I Eastern Surface Seal installed by I Irrigation '�-Approx. H P State Work Done_ Repair Work Done ❑ Type of Pump .� Well Destruction ❑ :Well Diameter Sealing Material )top 50'i v=t y Depth Filler Material (Below 50') O TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIRlADDITION DESTRUCTION l 1 available,wi within 200 feeto septic system .) if Public sew er is i Installation will serve: Residence Commercial` Other Number of living units: I Number of bedrooms Water table depth Character of soil to a depth of 3 feet: No. Compartments SEPTIC TANK ❑� Type/Mfg Capacity PKG. TREATMENT PLT. ❑ I h Method of Disposal Distance to nearest: well r Foundation r' Property Line LEACHING LINE No. & Length of lines Total length/size ¢ x �� Property J FILTER BED C] Distance to nearest: .Well � Foundation .PP.ert Y Line Size - Number SEEPAGE PITS i 1 Depth + SUMPS ,Foundatio%:— Property-Line Cl Distance to nearest: Weil OF_ - , *� DISPOSAL PONDS ❑ --- _ f 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. S, . Home owner or licensed agent's signature certifies the following: "I certify that-iri.the performance of the work for which this permit is issued, I shall not signature employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's nslring or sub subject to wookmant'scampensa certifies the following: "1 certify that in the performance of_the work-for-which-this.permit-is.issued,i shali employ p 1 tion laws of California." =� The applicant must call for all required inspections. Complete drawing on reverse side. *,e, KSigned X Title: Date: — OR DEPARTMENT USE ONLY' -Date P Area ®` Application Accepted by Pit or Grout Inspection by c Date V—If" spection by ate � y .� , + a Additional Comments: _ �r i 6385 ❑ Silk 466.6781 ❑ Lodi 369-3621 13 Manteca 823= 104 ❑ Tracy 835- Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 r FEE CK RECEIVED BY DATE ;M11 INFO AMOUNT DUE AMOUNT REMITTED CASH+.EH13-241REV.iin51Q Y�0 � — ,j EH 1429