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w - a * *� APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA 3 Telephone.(209) 466-6781 i 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. This application is made in compliance with San Joaquin Co bnty Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules an Regulations of the S- Jo quin r. Local,Health District. Job Address { City Lot Siz.gJ& PM _ r I Owner's Name -�° r± Address � -L� ri ' Phone f Contractor' Deg Address V��.�� 4� %r icense No. 713! K Phone ✓G TYPE,TOF WELL/PUMP: NEW tVELLi❑ WELL REP ACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION S TEM REPAIR ❑ OTHER ❑ .�.J`: DISTANCE TO NEAREST: SEPTIC TANK t. SEWER LIN DISPOSAL FLD. PROP. LINE —1 �" x I FOUNDATION AGR IC RE WELL OTHER WELL PITS/SUMPS 4i INTENDED USE TYPE OF WELL PROBLEM ARE CONSTRUCTION SPECIFICATIONS t ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing t " ❑ Domestic/Private ❑ Gravel.Pack ❑ Tracy Type of Casing Specifications y m Public e,art- ( Other, 5• ❑ Delta Depth of Grout Sea! Type of Grout__ " - .� -irrigation, Repair Approx-Depth*^--I-1 faster T••-••-• --•---Surface-Seal-Installed-by- -••"--.�r:- -- __.T _ :.. �- _ Repair Work Done ❑ Type of Pump ARE _ State Work Done _ Well Destruction ❑ Well Diameter ' �`` Seali g Material (top " Depth► ,. Filler Material IBe4 50') f TYPE OF,SFPT4E . OAK:. NEW INSTALLATION-€ I REPAIR/ADDITION !11, DESTRUCTION I I:'(No septic system permitted it public sewer is lavailable within 207.feet.) R Installation will serve: 'Residence Commercial lf1 Other Number`of living units: y ;;Number of bedrooms3 Cha{ctar"of soil°to a depth of 3 feaLY Water table depth 5 rSEPTIC,TANK . sType/M g i"I Capacity. No:Compartments PKG. TREATMENT PLT. D Method'of Disposal Distance to nearest: Well '• Foundations -'�" Property Line 4' �•.�,- -F- 4 LEACHING"LINE r ❑ No. & Length of lines t r Total length/size) � � } 4F,ILTER BED 1.- r' ❑ Distance to nearest: oundation Property Line r • FyEEPAGE PITS ('I Depth Size �- Number x SUMPS 0 Distance to nea est: Well,N) Foundation C0 Property Line DISPOSAL PONDS ❑ LI 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 DFstrict.' R , Home owner or licensed agent's signature certifies the following: 1 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 becortle subject to workrWn's compensation-taws of California.'-'.Contractor's hiring rlr sub-contracting signature 4 certifies the following: "1 certify that in the performance of the word for which this permit is issued, I shall eEploy persons subject to workman's lcompensa- l[ tiomlaws of California." f G t The applicant; ust call for required spections. 'Complete drawing on reverse side. 1 Signed X 9 Title: Date: ' r FOR 'DEPARTMENT USE ONLY Application Accepted by � __. I Date Area R//I a p Pit or Grout Inspection b } Date Final Inspection by Additional Comments =�✓i:w �S ! ! t ❑ Stk 466-6781 Lodi 369-362 ❑ Manteca a23-7104 ❑ Tracy 635-6385 # I Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O, Box'2009, Sik., CA 95201 r FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK 41 RECEIVED BY DATE PERMIT'NO. t t.EH 13-24(REV.r i k E1 - EH 14-26 f, s: