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APPLICATION FOR PERMIT SAN JOAQUIN;LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE.,..STOCKTON, CA 'Telephone (209) 466 -6781 PERMIT EXPIRES 1 YEAR FROM DAVE ISSUED (Complete in Triplicate). , " : tion is heebApplicmade to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is made Y f made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and RegulatEiins of the San Joaquin • Local Health District. st 'G "{ , - . s, ,„,t' ``•t � -/ .,� / � ate, '; City ,tr1/ > Lot Size PM Job Address •; '�`� ^ A Address 2� .,� Phone � l Owner's Name / 7 __ _ Phone License _,;VW AContractor r TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ * � PUMP-NSTALLATION O; -SYSTEM REPAIR ❑ a.. 7— -OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL.FLD M., - PROP. LINE i ,, FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE ` TYPE OF.WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Indus �❑ Open Bottom ❑ Manteca Dia. of Well'Excavatiori i Dia. of Well Casing ❑ Domestic/ Pack ❑ Tracy Type of Casing Specifications r i ❑ Public ❑ Other Depth of Grout Seal r+ Type of.Grout ❑ Irrigation �gpprox�pepth ❑ Eastern Installed-by ] s Repair Work Done ❑ Type of Pump H. P. to e Sealin Material (top 501) J i Well Destruction$ ❑ Well Diameter ; 9 j Depth FiHer Material IBelow 501 rp EI } TYPE OF SEPTIC WORK: NEW INSTALLATION,O 'REPAIR/ADDITION ❑ DESTRUCTION 171 (No septi6-system permitted if public sewer is l IVa available within 200 feet.) Installation will serve: Residence Commercial they} Number of living units: Number of bedrooms Water table�h r { �pth Character of soil to a depth of 3 feet: de Y 6 Capaciiyr No. Compartments I SEPTIC TANK ❑ Type/Mfg PKG. TREATMENT PLT. CJ F• Method of Disposal t Distance to nearest: Well L�lam!._ Foundation/ Property Line l LEACHING LINE L�No. & Length of lines Total length/size "� Pro rty L 0 0 ,� FILTER BED ❑ Distance to nearest: Well lU Foundation _ — pe 1" SEEPAGE PITS ElDepth•' Size " r Number r SUMPS ❑ Distance to nearest: '� WellLSO ,f Foundation 10 © Property Line O`6 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 rules and regulations of the San Joaquin Local Health District. k 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„hiringoi 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." The applica must ca11 for all required inspections. Complete drawing on reverse side. ` r Signed Title: J_ Date: FOR DEPARTMENT USE ONLY s f 0o, d Pit or Grout Inspection by t o Application Accepted by J Date L [ _ � - Area ( fT '21, Final Inspection b Date Date . Additional Comments: ❑ Stk 466&781 ❑ Lodi 369-3621 .Q Manteca 623-7104 O Tracy 835-6885 , r i, Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 } --r 3 FEE AMOUNT DUE AMOUNT REMITTED CK = RECEIVED BY DATE PERMIT NO. i L CASH �+ EH 73-24{REV.'i/9 51 EH 14-28