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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT rt 1601 E. HAZEL T ON AVE., STOCKTON, CA r' Telephone (2091' 66-6 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 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 3� S ,2 `�ik City 9h9�C*—/1 Lot Size PM Owner's Name J r �' !�a-L Address `r' 4 Phone Contractor_ Address tfO o; 7 •" - ' License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ `"""^ SYSTEM-REPAIR-❑ ..,OTHER-L) DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES - '„DISPOSAL FLD. PROP. LINE I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Weli-Excavation ' Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack Cl Tracy Type of Casing Specifications `l Public f_1 Other D Delta Depth of Grout Seal Type of Grout— rvN 11 Irrigation T Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _ (V Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth r Material,IBelow 50') r TYPE OF SEPTIC WORK: NEW INSTALLATION 1 r REPAIR/.ADDITION DESTRU TIO I i (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence-Z Commercial_ Other units: Number of bedrooms f,F A/O N � oDp 7-0 e Number of living � Character of soil to a depth of 3 feet: ' `-� Water table depth SEPTIC TANK ❑ Type/Mfg t Capacity ; �! No. Compartments PKG. TREATMENT PLT. ❑ ; !t Method of Disposal Distance to nearest: Well Foundation • Property Line x LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line I. SEEPAGE PITS ( 1 Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that t 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. M 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 certifies the following: "I certify that in the ormance of the wrk for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of Californi The applicant must all for all require LAn to dorawing on reverse side. G + Signed X �+` Title: Date: 2 —,r l EPARTMENT USE ONLY 3�a Application Accepted by Date Area N. Pit or Grout Inspection by Date Final Inspection by Ss � Date 3 6 Additional Comments: - ❑ Stk 456-15781 ❑ Lodi -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 95201 FEE AMOUNT DUE AMOUNT REMITTED K H RECEIVED BY DATE PERMIT'NO. INFO ♦.E1 -24IREV.fix5) r� EHH144-26 tJ YJ V lJ