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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL-1:01\1 AVE., STOCKTON, CA Telephone.(209) 466-6781 PERMIT EXPIRES( YEAR FROM DATE ISSUED (Complete in'Triplicatel 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 Ryles.and Regulations of the San Joaquin Local Health District. -' Jaa:.'t�s .. . :` �.' r , •',• /� e Job Address �L' City. Lot Size PM Owner's Name /w Address Phone /�� k �— l Contractor Address /r7W1q License No. ��-Phonc TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 'INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. o$Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction C1 Well Diameter Sealing Material (top 50') Q Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW 4NSTALLATION ❑ REPAIR/ADDITION ESTRUCTION ❑ INo septic system permitted if public sewer is �E l available within 200 feet.) ,. ri Installation will serve: Residene,cCommercial_ Other '° Number of living units; y Number of bedrooms Character of soil to a dept 3 feet: �� /�� A Water table depth SEPTIC TANK Ll Type), Capacity No. Compartments 3 �q PKG. TREATMENT PLT. ❑ '� Method of Disposal I Distance to nearest: Well Foundation Property Line LEACHING LINE No;'& Length of lines Total length/size FILTER BED Distance.to nearest:.-.Well _ 6 Foundation Property Line S t 11 SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ t Distance to nearest: Wel),__ Foundation Property Line F,DISPOSAL PONDS k I hereby csrtify that I have prepared'this application and thaf 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 rl employ any person in such manner as to become subject to workman's compensation laws of California:"Contractors 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 pbrsons subject to workman's compensa- tion laws of California." # ; ;•' '" t The applicant must caXforIreins s. Complete drawing on reverse side. � p Signed XG �—TitTitle: L �+ ate: f { �u € 4'FOR DEPARTMENT USE ONLY j e Application Accepted by ' Date U -;Area Pit or Grout Inspection by Date i Final Inspection by I ate O a�f Additional'Comments: t ❑ Stk 486-6781 ❑ Lodi 369-3621 ❑ Manteca 825-7104 ❑ Tracy 835-6385 i Applicant'Return all copies to: E=nvironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.', CA 95201 a.„---•r—�—•. ... FEE r.I. a_ �_ _. —CK'# _ t AMOUNT DUE/ AMDIJNT RCMTTED RECEIVED BY DATE, PERMIT NO. 1 INFO CASH �u •.�- :• � _ - - -- ---- �R----- +EH132alREv.tiie5} EH 1426 _