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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT IE 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) *6&-6"1-14-68-34c20 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) DZc�W ?��.. ` - - ! 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. Job Address City Lot Size PM ` �� v" A dress Phone Owner's ame F "33 3 Contractdf dress License No.,3�� Phone TYPE OF LL/PUMP: NEW ELL ❑ WELL REPLACEMENT ❑ DESTRUCTION { PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial 171Open Bottom 11Manteca Dia. of Well Excavation Dia. of Weil Casing f ❑ Domestic I Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1'50 0 7U t t 49 11 Public 17 Other Cl Delta Depth of Grout Seal Type of Grout I I Irrigation —.-Approx. Depth i I Eastern Surface Seal Installed by - Y" ' Repair Work Done ❑ Type of Pump H.P. State Work Dane ' Well Destruction Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR)ADDITION I DESTRUCTION l I (No septic system permitted if public sewer is �11 available-within 200 feet.) Inst tion will serve: 'Residence_ Commercial_ Other Number o units: Number of bedrooms r Character of soil t depth of 3 feet: Wat a depth n SEPTIC TANK ype/Mfg Capacity No. Compartments 1 PKG. TREATMENT PLT. ❑ Method of Disposal �. ,. Distance to rest: Well Foun Property Line . _ 'j- r it l LEACHING LINE ❑ No. & Length of lines Total length/size t FILTER BED ❑ Distance to Weare Well Foundation Property Line 1�v SEEPAGE PITS I'] th Size _ Number SUMPS l 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 C 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-.. €L tion laws of California." k The applican ust call r all required inspect i ns Complete drawing on reverse side. I � Signed X Title- Daattee: FOR DEPART N Application Accepted by Date 7 Area X`� Pit or Grout Inspection by Date ' 1 Final Inspection b Date. a Additional Comments: /CO ' ❑ Stk 466-6781 od' -3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 eao z � Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk/CA 95201 —"/�a` ` a FEE l INFO AMOUNT DUE AMOUNT AMOUNT REMITTED /CASH RECEIVED BY DATE QPERMIT'NO. { + EH 13-24(REV.I i n 51 ,2S,0 �a� f 7� 1= - 13 1i1(y (Jp 7 EH 14-26