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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 hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application rs made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for welt/pump and the Rules and Regulations of the San Joaquin Local Health District. n (� e- 4 A, Kr.I City _� Lot Size _� PM Job Address J� —�_— -b'� ' Addressf� _ Phone '�— Owner's Name --7 S� X �- � 1j0 ( License No. _-- t,none u u— ., Contractor -o r "Address _ ' DESTRUCTiON ❑ _ -------TYPE-OF WELL:/PUMP:.- �r...�.r NEW,WELL,'i�„,,,, ._,.._.WELL REPLACEMENT OTHER C r ❑ SYSTEM REPAIR ❑ i TYPE OF SF.PTIG"WORK: +NEW INSTALLATION i 1 REPAIRrADDI710N DESTRUCTION I � afvailabQelwithin 2fi0 feetil� ,f publ,c sewer is - � t will serve:—Residence V^'Commercial -! PUMP INSTALLATION SEPTIC TANK -SEWER LINES DISPOSAL FLD.�.— PROP- LINE DISTANCE TO NEAREST_: _.. - AGRICULTURE WELL _ OTHER WELL _.— P1TS/SUMPS = — No., Compartments _. FOUNDATION - Meihod,of Disposal PKG. TREATMENT PLT. ❑ � � 4---��`�+ Well { Foundation '^" -�"�'" _ Property Line, — TYPE OF WELL PROBLEM AREA)' CONSTRUCTION SPECIFICATIONS INTENDED USE El Industrial L1 Open Bottom (� Manteca t Dia. of Well Excavation __— Dia. of Well Casing F)Domestic/Private ❑ Gravel Pack C Tracy Type of Casing ~ ' ; Specifications+' Type of G rout (i Puhtic Cl Other D Delta Depth of Grout Seal _ — • rl I Imitation _ pprox. Depth I 1 Eastern Stiriace Saal Installs y r 'Repair Work Done L Type of Pump —.. H.P• State Work Done —— f-^ Weil Destruction ❑ Well Diameter �. Sealin Material ltop 50'1 —. 9 , - - Depth _ Filler Material IBelow 50') -_- i TYPE OF SF.PTIG"WORK: +NEW INSTALLATION i 1 REPAIRrADDI710N DESTRUCTION I � afvailabQelwithin 2fi0 feetil� ,f publ,c sewer is - � t will serve:—Residence V^'Commercial -! 3Other� Installation Number of living units: A.— Number of'bedrooms, -; t Water table depth Character of soil to a depth of 3 feet t - Capacity_ SEPTIC TANK f7 Type/Mfg" — No., Compartments _. r - Meihod,of Disposal PKG. TREATMENT PLT. ❑ � � 4---��`�+ Well { Foundation '^" -�"�'" _ Property Line, — Distance to nearest: _ LEACHING LINE I No. $ Length of lines .� 1�.� - " Toja! length/size— — Property Line Foundation FILTER BED ❑ Distance to nearest: Weil ' _ SEEPAGE PITS I 1 Depth Size Number — SUMPS LI Distance to nearest: Well Foundation Property'Gne DISPOSAL PONDS ❑ 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 Califomia." Contractor's hiring or sub -contracting signature cartifies 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." e. The applicant must call for all r quired inspections. Complete drawing on reverse std Titles�L✓� Date: Signed X_ ,_ FOR DEPARTMENT USE ONLY Application Accepted by Pit or Grout Inspection by J Date Area 1 7 Date ._ ._ Final Inspection by 5L-� _ Date Additional Comments: _ ❑ Stk 466-6781 C' Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy M-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E, Hazelton Ave., P.O. Box 2009, Stk-, CA 95201 EH 13.24 (REV. , /4 s) EH 14-26 f �4 FEE INFO CK RECEIVED BY DATE PERMIT'NO. AMOUNT DUE AMOUNT REMITTED CASH