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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT '' �1.•.� 1601 E. HAZELTON AVE., STOCKTON, CA '_ Telephone {209} 466-6781 i PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ry {Complete in.Triplicate) j. Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. T'Ns 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. - . ak , '7.1.,.4 "<ax '_�' ` ,. r c,. .r - � .. 1 -x' -` >"S <•�, I Job Address cit _ST �o Lot Size 2PM Owner's Name") ,fl MY I j ?Airne�� —Address" '_MA,:14E Phone —,17 ContractorAddress License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 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 n i ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing V( � ❑Domestic/Private El Gravel Pack ❑ Tracy Type of Casing Specifications \� V � I ❑ Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout Q l I ❑ Irrigation - ---Approx. Depth . ❑ Eastern Surface Seal Installed by !v Repair Work Done. ❑..- .Type-of.Pump --- —H.-P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAII!/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is vailable within 200 feet.l Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water cable depth Q SEPTIC TANK Type/Mfg Capacity.-_.' ' No. Compartments PKG. TREATMENT PLT. Method of Disposal jDistance to nearest: Well Foundation`- ��—Property Line 1 LEACHING LINE ❑ No. & Length of lines # Total length/size FILTER BED ❑ Distance to nearest: - Well Foundation Property Line SEEPAGE PITS ❑ Depth Y Size Number SUMPS L1, .Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work willbe done in accordance with San Joaquin county ordinances, state laws, and j 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 employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature r certifies the following:"I certify that in the performance of the work for which thisrrnit is issuedI shall employ pe , p y persons subject to workman's compensa- tion laws of California." The applicant m" t call for all required -nspecti . Complete-drawing on reverse side. ,-"Signe Title: 4 Date: FOR DEPARTMENT USE ONLY AaApplication Accepted bu+� pp p y Date Are Pit or Grout Inspection b Date Final Inspection by Datx_� . Additional Comments: �" 1 ❑ Stk 466-6781 El Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 935-6385 t I Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. eox 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. INFO +'EH 1324(REV.7ia51 0,2 -- S �_ .s.z ; - �f/ ... - �-M 1 EH 14-26 °�•/ �7. I-F7'-1 1�' .