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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED I l (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... iI 0 Job Address Cityl� ii/IL/if�i0lrnt Size� ?C� X /3'1 PM I Owner's Name Address Phone J f E Contractor � Address � License No �:� Phont� TYPE OF WELL/PUMP: �I NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMPi INSTALLATION ❑ -,� _SYSTEM REPAIR ❑ t OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. . PROP. LINE �l. FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ih INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS + 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications r n Public F Other 71 Delta' Depth of Grout_Seal Type of Grout f l`. I I Irrigation .I'-Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Typ` of Pump H.P. l I State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50')r Depth Filler Material ISelow 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION i I DESTRUCTION I 1 (No septic system permitted if public sewer is available within 200 feet.) Installation will serve:4 Residence" Commercial'_s 1,Qther"'•"'-° rt. R' Number of living uii ts-- Number of bedrooms :. Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity f(c ';a2Na, Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Foundation - r; Property.Line ;I. t tS LEACHING LINE No. & Length of lines Total Iengthlsize i FILTER BED / Distance to nearest: l fl; Foundation° }P+ h tV �_ Property Line SEEPAGE PITS i I Depth ` ' Size '��✓� Number SUMPS I fistance to nearest: Well Foundation tr4 Property Line 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 Di?;trict. �" f Home owner or licensed agent'"s signature certifies the following: '9 certify that in the performance of the work for which this permit is issued, I shall not employ any person in such mariner as to become subject to workman's cnrnprensation 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." I s The applicant must call for 11 required inspections. Complete drawing on reverse side. :- I Signed X r Title: Date: F DEPARTMENT USE ONLY I Application Accepted by �L Date 2 7 Area A-51 . Pit'or Grout Inspection by +I Date Final Inspection by Date Additional Comments: It ❑ Stk 466-6781 ❑ Lodi i 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 i Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE gMOUNT DUE AMOUNT REMITTED CK' RECEIVED BY DATE _ -INFO e.. .. . . .--CASH PERMIT'ND.- --._ _ .�._- +.EH 13-24 IREV EH 14-28 `try. O i