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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209) 466-67$1 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 County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. CA 11 Job Address 3-7� City Lot Size PM Owner's Name Addressa�3 Phone �� l Contractor6aAddress _ Li ense NQ. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT/LI DESTRUCTION❑e a. PUMP iNSTALLATION ❑ SYSTEM/REPAIR ❑ OTHER p� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PR ,. LINE FOUNDATION AGRICULTURE WELL OTHER WE PIT�ISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA tCONSTRU ECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Mantecao Well Excavation Dia. of Well Casing r ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy a Typ�of Casing Specifications 1-1 Public ❑ Other elta ®Depth of Grout Seal Type of Grout I I Irrigation _.Approx. De I 1 Eastern Surface Seal Installed by Repair Work Done ElType of Pu H.P. State Work Done_ t, Well Destruction ❑ Wel] Diameter Sealing Material (top 50') W Depth r Material {Below 50'1 G] TYPE OF SFPTIC WORK: NEW INSTALLATION l 1 REPAI N DESTRUCTION I 1 INo septic system permitted if public sewer is ( , available within 200 feet.) w Installation will serve: Residence_ Commercial Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth r _ f SEPTIC TANK ❑ Type/Mfg. f Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well 1 Foundation Property Line l " . LEACHING LINE r ❑ No. & Length of linesF T Total length/size FILTER BED-`\— —0 Distance to nearest: Well ! Foundation Property Line SEEPAGE PITS I 1 Depth Size _ Number , f SUMPS ❑ Distance to nearest: Well Foundation 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 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 t 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 mcall for all require i cY ns. Complete drawing on reverse s" e. Signed Title: . . . -- Date: FOR DEPARTMENT USE ONLY Application Accepted by _ Date ~ Area Pit or Grout Inspection by Date Final Inspection by Data Additional Comments: ❑ Stk 466-6791 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 935-6M5 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- INFO /�(`�� CASH +.EH 13-216(REV.1/X 51 90 , L T" EH 1426 ��••V//"' NJ S