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APPLICATION FOR PERMIT SAN JOAQUIN.LOC AL HEALTH DISTRICT 1601 E. HAZELTON AVE.,- STOCKTON, CA 1 Telephone (209) 466-6781 l' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED..;€ P r (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. Pf.µ Job Address City Lot Size 26( Y �PM. LP Owner's Name Address Phone Contractor f Address License No. Phone 9y� 72Z TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP,QINSTA iLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ r DISTANCE TO NEAREST:-SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE t e FOUNDATION;*P!%, _ AGRICULTURE WELL OTHER WELL PITS/SUMPS V INTENDEf2 USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i ❑ ,Industrial ❑ Open Bottom Manteca Dia. of Well Excavation Dia. of Well Casing t ❑ Domestic/P,rivate ❑ Grayei Pack O Tracy Type of Casing Specifications (!•� ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of>Grout _j � is I ❑Irrigation -----Approx. Depth ❑ Easterny Surface Seal installed by " J t Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501j Q4str Depth .Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION 171-(No septic system permitted if public sewer is j w available within'-200 feet.) Installation will serve: Residence Commercial= Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: �*a !�, Wa tier t b e idepth SEPTIC TANK ❑ Type/Mfg Capa ity'� ►.l Nd�Compartments PKG. TREATMENT PLT. ❑ r i Method of Disposal 1 3 t 1 Distance to nearest: Well Foundation Pro a Line � - 4-617 2� � r�rty LEACHING LINE OiNo. & Length of,lines T t ! lengfh%site r t 4 t ' ILTER BED ❑ Distance o nearest:' r Foundation m ProprryLine hV IL SEEPAGE PITS 1.Depth Y r r i p Size AV umber SUMPS ❑ .Distance to nearest: Well oundation Proper�ty,Lire :y DISPOSAL PONDS ❑ heieby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rule's and regulations of the San Joaquin Local Health District. . I , at>t \ -2 Home owner or licensed agent's signature certifies the`following: "I certify that in the performance of the"ork for which this permit is issued, I shall not empioy any person in such manner.as_to_become subje`ct.to workman'"s compensation^law's of Calif ornia*'0Contr'actor'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 g; sons subject to workman's compensa- tion,laws of California." �k Thejapplican must call for a1T)ree d inspe ions. Complete drawing on reverse side. / Signed X e,/f,/ Title: tt Date: .f ��Y 4 `t P FOR DEARTIIAENT USE ONLY t ` Application Accepted by '� $ Date (�6�_&IA ea� Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Stk 466 6781 ❑ Lodi 369-3621 Manteca 823-7104 ❑ Tracy 835-6385`� EApplicant-- Return all copies to: Environmental Health Permit/Sere-ices 1601 E. Hazelton Ave.; ;0}Bo)2dM,fStk.,_CA.95201.,.......-._ .- ....- _, ....+ _F.EE.. ...AMOUNT`DUE`"�"`AMOUNT"REMITT`ED -SCK _rRECEIVED Ef DATE -PERMIT N0. INFO CASH 5 1�, + EH 13-24(REV,i/e 5) . .. ,•� EH 1428 '� -�....:v 3 f