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APPLICATION FOR PERMIT SAN JOAOUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM`DATE ISSUED � . ,. _. „,•ter r . ,« (Complete infTriplicate) 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 Ryles and Regulations of the San Joaquin Local Health District. 'f Job Address tt`µ+r-+ x City' 44Lot Size 0 PM Owner's Name < . /(1 �, �G Address _ x/21l J ! [f f�� Phone J Cohtractor _ Address I License No. Phone TYPE OF WELL/PUMP: NEW PUMP-INST LL,TIOELL C1 N'"❑--- WELL REPLACEMENT-1-1._i SYSTEM REPAIR DESTRUCTION0 HR Ll DISTANCE TONEAREST: SEPTIC TANK SEWER LINES ¢ 4 DISPOSAL'FLD. PROP. LINE FOUNDATION '' ti' AGRICULTURE' ELL OTHER•WELL PITS/SUMPS INTENDED USE (TYPE OF VII LE Lf �'� PROBLEM AREA CONSTRUCTION SPECIFICATIONS r ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public C Other ❑-Delta---, Depth of Grout Seal Type of Grout ❑ Irrigation I —Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Weli Diameter—' Sealing Material (top 50') 7;' Vll"tDepth-_ Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.l Installation willserve: 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 r t PKG. TREATMENT PLT'❑ Method of Disposal Distance to nearest: Well Foundation Property Line t } LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line r t l SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation P-roperty'Line DISPOSAL PONDS ❑ i 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 i employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following:"1,certify'that in th rmance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of C ia:"', : - 1 The applicant' st all for all re fired inspections. Complete drawing on re-vUse side. Signed Title: d Date: -2f( FOR DEPART ME USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date final Inspection by Date - 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 r FEE 4 INFO AMOUNT DUE AMOUNT REMITTED C RECEIVED BY DATE PERMIT"NO. ':+•�EH`13=24'IREV.i/e'51'--.,.. —�.F i�+ar�.-.^":.1.- _ ..��-,-1.�,,».,.��,,,�„•,,.,,..r .�- .. . . --. �,� EH 1428 �� S