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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ! 1601 E. HAZE T ON'AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I (Complete in Triplicate) Application is he,eby 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. I �iC✓ �'2.. :mac +? Job Address c_ City lLoz 1 - -.PM r y Owner's Name _ 3 1 V Address J r F P�,-P / _- Phone Contracto AddressJ�C� ense No. Phone Zs J TYPE OF WELL/PUMP: NEW WELL ❑ ;WELL•REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR-[] OTHER-0 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 —.0-industrial 4 --- C7-Open Bottom - —❑ Manteca Dia. of Well Excavation - Dia. of Well-Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f'i Public f OtherI Cl Delta Depth.of Grout Seal Type of Grout _ ISI Irrigation Approx. Depth I I Eastern Surface Seal Installed by r - Repair Work Done ❑ Type of Pump H.-P. t State Work Done Well Destruction ElWell Diameter Sealing Material Itop 50'1 Depth De - - P f Filler Material- 50'1 _ TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION S+--&Er`TRUCTION I I INo septic system permitted if public sewer is ,.P_1�1-�� _ available within 200 feet.) r Installation will serve: Rest ence Ll__C ommercial the r f Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth 1' SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments ��pp PKG. TREATMENT PLT. ❑ I Method of Disposal trt Distance to nearest: Well Foundation Property Line I LEACHING LINE CVIS&f.ength of lines Total length/size FILTER BED ❑ Djstance to nearest"^'Weil• Foundation. - "Property Line _� ' SEEPAGE PITS th Size. Number G SUMPS kj-- istance to nearest:, �`Well �,4„7-6. undation 731)- Property Line.- r1,, 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-Diltrict.• ,� I Home owner or licensed agent's signature certifies the following:�. 'I certify that in the performance of the work for which this petit is issued, i shall not 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: "4 certify that in the performance of the work for which this permit is issued, I shall employ persons subiect to workman's compensa- tion to f California " _ The applican t calf f` all re�uiredlpec I ns. ompete'drawing on r verse side. �` rSigne .^'Title: �.., — . .. ' pate: FOR IDEPARTM T USE ONLY Application Accepted by : � Date ea Pit or Grout Inspection by Date ` Final Inspection Dat Additional Comments: t `"� ❑ Stk 466-6781 ❑ Lodi 369-3621 f ❑ Manteca 823-7104 ❑ Tracy 835 6385 F i Applicant - Return all copies to: Environmental Health Permit/Services 1601 E: Hazelton Ave., P:O. Box 2009, Stk., CA 95201 L FEECK INFO AMOUNT DUE AMOUNT REMITTED CASH w RECEIVED BY DATE PERMIT"NO. is 1 ., EH 3-24 , s, , EH 14-26 .. S f.1 r