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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES I YEAR FROM DATE ISSUED C (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.r `I Jab Address ��U� 'c City Lot Size AL1ZC PM I Owner's Name Address Phone I Contractor Address 0• I M License No., t3 Phone 46A 36-0 7 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL. FLO. PROP. LINE rn j FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS,' E3Industrial ❑ Open Bottom 11Manteca Dia. of Well Excavation ` Dia. of Well Casing Ll Domestic/Private ❑ Gravel Pack LJ Tracy Type of Casing Specifications (4 ❑ Public ❑ Other ❑ Delta Depth of Grout Seal ' Type of Grout ❑ 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 50') Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION ❑ DESTRUCTION ❑,(No septic system permitted if public sewer is ----- available within 200 feet.) Installation will serve: Residence-XL Commercial_ Other ; 1 i Number of living units:--A— Number of bedrooms 3 * � Character of soil to a depth of 3 feet: 1 4 �'� Water table depth ' SEPTIC TANK Type/Mfg j11Shl ■ GoiJG12CTE __ capacity_I(o O0 No. Compartments Z 1 PKG. TREATMENT PLT. ❑ ,f t Method of Disposal Distance to nearest: Well (0010 <fProperty.Linel 149C LEACHING LINE -19 No. & Length of lines FILTER BED ❑ Distance to nearest: Well_J Do Foundation A 9 Property-L-ine r04 i SEEPAGE PITS ❑ Depth Size - Number IIf SUMPS ❑ Distance to nearest: Well FoundationProperty Line DISPOSALYPONDS ❑ herebyycertify-thatA have prepared this application and that the worewill be done in accordance with San Joaquin county ordinances, state Yaws, and rules and regulations of the San Joaquin Local Health DistrictZ ` ` mance of the work for which this permit is issued, I shall not Home owner°'opicensed agent's signature certifies the following: "I certify that in the perfor 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:'9 certify that in the performance,df the work for which this permit is issued,I shall employ persons subject to workman's com. nsa- •lion laws�af California." .i .on applicant must call for all required ipections. Complete drawing on reverse side. Signed .-� Title: Date: S X '�' 942 F R DEPARTMENT USE ONLY Application Accepted by Date Area I I;�;-Af�. 4 - Date Pit or Grout Inspection by Dae Final Inspection y I- r4(( l i6eAl 65 e,e ;. Additional Comments: ` ❑.Stk-.,466-6781.❑-Lodi, 369- 1 ❑ Manteca 823-7104 ❑ Tracy 835-63$5 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 Fe i° CK w- +,,_FEE— OUNT-DUE——AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. INFO + .EH 13-24(REV.5 i e 5)� t]. C7C� r. ,ti w, .j iL I EH 14-28 - e "