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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA y' 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. T ' 4pit cation,is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations C ta San Joaquin Local Health District. y aCz Job Address Q I'■ City Lot Size M I.6mt��14 r. . Owner's Name '` Aii'dress T Phone `,►� _ - - �,,.^.r _ 1� Contracto Address License No. < Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMEN ❑ DESTRUCTION LD j PUMP INSTALLATION L] SYSTEM AIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEW LINES DISPOSAL FLD. PROP. LINE FOUNDATION AG RI LTUR ELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM ARE CONSTRUCTION SPECIFICATIONS Industrial �❑ Operi Bottom �`._;.❑ Manteca Dia. of Well Excavation Dia. of Well Casing r � ; 1 n..Domestic/Private 0 Gravel 0, ❑ Tracy Type of Casing Specifications ' Cl Public ❑ Other' «�' . ❑ Del Depth of Grout Seal Type of Grout —. (� k t I Irrigation _.-Approx. Depth l I stern urface Seal Installed by r: Repair Work Done L7 Type of Pump' H.P. State Work Done _ Well destruction © Well DiameterSealing Mat ria) (top 50') Q t Depth Filler Material [Below 501 TYPE OF SEPTIC WORK: NEW INSTAL TION iwr REPAIR/ADDITION l ] DESTRUCTION I I Wo septic system permitted if public sewer is r: I available within-20D,feet.l- . .w Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet:. Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments ` G. TREATMENT PLT. ❑ Method of Dispos ' Distance to nearest: Well:.y_I� Fou dation Property Line ^r + — LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well es Foundation s Prcpert Line f SEEPAGE PITS fl Depth J Size Number SUMPS ❑ Distance to nearest: Well.Au Foundation,1-0 Property Line s DISPOSAL PONDS ❑ I ereby certify that I have prepared this application grid that the work will be done in accordance wiwith 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 employ any person in such manner as to become subject to workman's compensation laws of California:" Contractor's hiring or sub-contracting signature i certifies the following: "'I certify that in the performance of the work for which this permit is issued, I shall employ p&sons subject to workman's compensa- tion laws of California."' F /,� The applicant t 'for all re 'red inspe ions. Complete drawing on raVerse side. t" M Signed X r' e �C1�Zdc? Date: FOR .DEPARTMENT USE ONLY Application Accepted by, Date /r - Area {— 1 or Grout Irtj�pection by Data Final Inspection b�� i' Date Additional Comments: ❑ Stk 466-6781 7 Lodi 369-3621 ❑ Manteca 523-7104 El Tracy 835:6385 ' Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009 Sik., CA 95201 r It FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED 13Y DATE PERMIT NQ. +.E1 -241REV.'i/Hs1 ` 's EkH144-28