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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-67$1 PERMIT EXPIRES 1 YEAR.FROM DATE ISSUED k , -(Complete in,Triplicate) . V a Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This applic"on 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. f /. f r r Job Address _� City Lot Size 'e-9-A Z7 PM Owner's Name ss44Phone Contractor Address '�— ' License No. 'Phone TYPE OF WELL/PU NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ t PUMP INSTALLATION p SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL " PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA..-CONSTRUCTION-SPECIFICATIONS'' i ❑ Industrial ❑-Open-Bo ttorrr �❑ Manteca Dia. of Well Excavation Dia.'of Well Casing ❑ Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing Specifications' ❑ Public ❑ Other O Delta Depth of Grout Seal Type of Grout s. ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. ' State Work Done Well Destruction ❑ Well Diameter Sealing Material (top'501) Depth Filler Material (Below{.50'I N 1Z TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is x vailable within 200 feet.) ` �y Installation will serve: Residence— Commercial Other, lJ Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Li ;Type/Mfg j - F.r Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well ' FoundationProperty Line t LEACHING LINE ❑ No. & Length of lines Total length/size ' FILTER BED ❑ Distance to nearest: Well - Foundation Property Line R I SEEPAGE PITS ❑ Depth Size "Number _ r SUMPS ❑ - Distance to nearest: Well 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 rules and regulations of the San Joaquin Local Health District. 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 certifies the following: "I certify that in the performance of the work for which this permit is issued,employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub tion laws of California." contracting signature I shall employ persons subject to workman's compensa- ..� F The applicant ust c for all quired 'nspections. Complete drawing on reverse side. Signed Title: t� - _ Date: FOR DEPARTMENT USE ONLY Application Accepted by Date n 5-2 —f 7 7Area Pit or Grout Inspection by Date Final Inspection by ILL46NXILDat Additional Comments: ® - ❑ Stk 466-6781 ❑ Lodi 369.3621 Manteca 823-7104 ❑ Tracy 83546385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Sfk., CA 95201 j FEE AMOUNT DUE -AMOUNT REMITTED CK* RECEIVED BY DATE PERMIT N0. INFO r EH 13-241REV.7/881 EN 1428 `� - LL �''� `