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APPLICATION FOR PERMIT SAN`JOAO.UIN LOCAL HEALTH DISTRICT " 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 3�� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate), n 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.Ord'+nance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin ; Local Health District. � City Job Address �I /} } Lot Size PM f Phone -�Zl� Owner's Name Address ( � �. C �_ �f ftj s �G d icense No. Phone Contractor Addie TYPE OF WELL/PUMP:- �. NEW WELL ❑1fl� WELL REPLACEMENT ❑ DESTRUCTION ❑ t 4 ` ' `N A j W61,4-.SYSTEM REPAIR OTHER ❑ a4%- P I �,4��bQTIpN ❑ A , '��e " � � DISPOSAL FLD. PROP. LAVE DISTANCE TO NEAREST:SEPTIC TANK,_ SEWER LINES FOUNDATION._ h- -AGRICULWRE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL t PROBhENF AREA� CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom r-.❑ Manteca-'i /Dia. of Well Excavation Dia. of Well Casing � t Specifications Ik pomestic/Private ❑ Gravel Pack; ❑ Tracy 4T�ipe of Casing I " T of Grout i ❑ Otter Delta � DJsth of Grout Seal Type❑ Public ❑ Irrigation 2t3-5-Approx. Depth ❑ Eastern ' .a Surface Seal Installed by Type of Pumg.4 Ag p �A- H.P. State Work Done u Repair Work Done � : � A j Well Destruction ❑ Well Diameter " Seating MaErial [top 50'1 �� `� ��iN 4th Filler_Material_(%e ow_W') Dep Z-f TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (Noseptiwit stem permitted if public sewer is availablel (4 f Installation will serve: Residence— Commercial_ (Other r Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg j Capsacity No. Compartments PKG. TREATMENT PLT. ❑ 1. Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED LlrDid'tance to nearest: Well I Foundation Property Line �! 4 SEEPAGE PITS ❑ Depth Size t Number � SUMPS ❑ Distance to nearest: i Well Foundation Property Line r t v ' DISPOSAL PONDS ❑ y 4 I hereby certify that I have prepared this application and that the work wilf+be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of`the San Joaquin Local Health District.. I Home owner or licensed agent's signature certifies the followi6g: "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 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 m f all re d inspections. Complete;pdrawing 0 e Nde. Si ned t Title: Date: g IR DEPARTMENT USE ONLY [/ k Date_ 4" - Area Application Accepted by � �f j Date 4 U I Pit or Grout Inspection by Date ! Final Inspection by Additional Comments: _ . ( ❑_Stk66- 46781,„ O.Lodi.,369--3621.._.....❑-Manteca_1823-7104 ❑ Tracy� _ 83:r6385 �------ f Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTEDCK- RECEIVED By DATE PERMIT NO. INFOJ-�.CA,sm,.+ i~ , �' + EH 13-24(REV.1/a 5) -1 EH 14-28 4J _"'"