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0 Z ] APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ' 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 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. a-?A 3 A, Job Address '! M/ L. QL/L4 City Lot Size PM Owner's Name /'�/� Address S�4lr�t! - '`-- Phone ContractorZ& f'YOM Address E ��S �/� License No. Phone_7 /�� ! ,TYPE OF WELL/PUMP: NEW-WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK ,SEWER LINES _ DISPOSAL FLD. _ PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f ❑ Industrial ❑ Open.Bottom.---.Cl Manteca Dia.-of Well Excavation ....Dia.-of-Well-Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications t l`l Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout 1 1 Irrigation --Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type'of Pump H.P- State Work Done _ We$Destruction ❑ Well Diameter Sealing Material ftop 50') � Depth Filler Material (Below 50') ,TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION DESTRUCTION I I iNo septic system permitted if public sewer is' - S available within 200 feet.) y Installation will serve: Residence_ Commercial_ Other ' Number of living units: Number of bedrooms , Character of soil tosa depth of 3 feet: Water table depth C SEPTIC TANK « : ❑ 4Type/Mf9 Capacity No. Compartments PKG"TREATMENT PLT 171 t Method of Disposal Y" +. * ° '• k+" Distance to nearest: Well Foundation-proper y Line ] LEACHING LINE % No. & Length of lines ` dd ` TTotal length/size L ' FILTER BED V, Q Distance to nearest: Well 160 Foundation 70 Property Line ;SEEPAGE PITS f'1Depth y Size f Number r SUMPS ❑ Distance to nearest: Welles 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 i rules and regulations of the San Joaquin Local Health District. . - Il ,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, t shall not i employ any person in such manner as to become subject-to work man: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." y The applicantS1 call for equir inspections. Complete drawing on r ers ide. k Signed X Title:' #t'- - Date: �� ✓ o FOR DE RTMENT USE ONLY Application Accepted by Date �r Area Pit or Grout Inspection by Date Final inspection by Date � t _ 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 CK VI FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'N0. 11-i 1324 IgEV. --(7(� r� 1't K k..�r,.` n'� - 4- -`� \ l,7 • 1'�a5a��0. ,.r. - *--r EH 14-2e