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' APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone {209} 466-6781 tl PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.I 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 9 �N Owner's Name ddress Phone I Contractor's NameM�b�i�9 _(�i�7Fp License No. 24 Phone TYPE OF WELL/PUMP: ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ IM CTUMM INSTALLATION WE4' MYSTEM REPAIR ®9 OTHER ❑ DISTANCE TO NEAREST: SEPTIC TA SEINER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS IN- INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well ExcavationDia. of Well Casi lg � -4Lv W7Domestic/Private ❑ Gravel Pack —0-Tracy- -Type of Casing -Specifications Z 6ZA44G ❑ Public ❑ Other I ❑ Delta Depth of Grout Seal Type of Grout IM S 7 ❑ Irrigation Z392Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ;0- Type of Pump 3 H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 I IM Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments �� P PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size I IM FILTER BED ❑ Distance to nearest: Well Foundation Pro t ' � perry Line } t SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line c � DISPOSAL PONDS ❑ ! t E 3 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. IM Home owner or licensed agent's signature certifies the following: "I certrfy that in'the performance of the work for which this permit is issued, I shall not a _- employ any person in such manner as to become subject to workman's compensation Isws 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." _ f I I The applicantst cal r all required inspections. Complete drawing on`reverse side. a I� Signed Title: --- -_ -'- Date: SPA i ''POR�'DEPART NTTUSE O.NLY � f Application Accepted byDate Ares C3 Z Pit or Grout Inspection by Date Final_Inspectionby. , ate _ a Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E:Hazelton Ave., P.O. Box 2009; Stk., CA-9W01- FEE A95201 FEE AMOUNT DUE_ AMOUNT REMITTED INFO CASH CK# RECEIVED BY DATE PERMIT NO. -•. . + EH 13-24(REV.101$3) iZij —q o4 EH 14-26 g O H I