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rk " f 1 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 4 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6787 I PERMIT EXPIRES 'I YEAR FROM DATE ISSUED ' ` q1 (Complete in"Triplicate) s n,eoo b i 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 I 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. „4 r �� c , . Gty.. %'it"Lot Size �' PM Job Address l Owner's Name�' '1ti r✓�'� ' -Address' .630 Phone " j ContractvlC�'�t�u[ Address License No,�"o2�at � Phone TYPE OF WELL/PUMP: NEW WELL ❑ '—-WELTREPL'ACEMENT-❑-" "" " DESTRUCTION'❑ PUMP INSTALLATION ❑ t SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE " i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS " 1, INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ,.❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ' 7 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done E) Type of Pump ' H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') A # Depth Filler Matefial (Below 50') i TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION.p '(No septic system permitted if public sewer is �" - available within 200 feet.) LJ Installation will serve: Residence Commercial Other E i Number of living units; _L_ Number o droo s / ek c�' �Jl z�_ water tabie`de the Character of soil to a depth of 3 feet: _ p I SEPTIC TANK R Type/Mfg Capac}ty t - No-Compartme "- r ;PKG. TREATMENT PLT. ❑ �• i r r MethodsDim s'ah k Cl 1 Distance to nearest: Well � Foundation Property Line LEACHING LINE U? No. & Length of lines 0 Notal length FILTER'BED ❑ Distance to nearest: Well r 60 Foundation f Q 3 Property Line SEEPAGE PITS P""Depth 5 Size yo�- lumber SUMPS ❑ Distance to nearest: Well /SLS Foundation / —Prnpeity Lme 1 'DISPOSAL PONDS ❑ £ F 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 regulationsof--the-San-Joaquin-Local-Heal#h-District-- �- -zi -- - —�•- --- - ---- 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 s 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-tion-laws of California." k The applicant mtAt call fo all required inspections._Complete drawing on reverse side. Signed-----a4.- ...._, ,.,.Title- ..----- �, Date: .Y, k ,,. # FOR DEPARTMENT USE ONLY Application Accepted by Date w� Area '✓ 6/tr Grout Inspection by Date( Final Inspection by Date `#'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 95201 FEE AMOUNT DUE AMOUNT REMITTED CK# RECEIVED BY DATE PERMIT"NO. INFO ` CASH 4-D-7 ` + EH 13-24(REV.,I/a 5) Li S� �0 / � � �� L� EH 14-26 111 _