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!I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE.,,STOCKTON, CA Telephone {209} 466-67$1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED y �,�(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 t 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. - ! 1 Job Address JIG ! !D /V � City Lot Size PM F Owner's Name l Address 1, , , -Phone D —� 171 7S Contract r r G+�x�C Acldress t'c✓ 1 V 7 t License N J0` phone iso ^`7 �Q TYPE OF WELL/PUMP: I-NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ e PUMP INSTALLATION-❑ v SYSTEM REPAIR El OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES z- DISPOSAL FLD. PROP. LINE FOUNDATIONAGRICULTURE WELL OTHER WELL ' PITS/SUMPS INTENDED USE TYPE OF'WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial C1 Open Bottom ❑ Manteca r. Dia!of Well Excavation Dia. of Well Casing I ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications i. ❑Public ❑ Other ; ❑'Delta r Depth of Giout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface'Seal Installed by Repair Work Done ❑ Type of Pump H.P. A State Work Done } Well Destruction ❑ Well Diameter' Sealing Material {top 501 i Depth iller Material IBelow 501 s i TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ (REPAIOADDITION Rr DESTRUCTION ❑ (No septic'system permitted if public sewer is J available within 200 feet.) p'- Installation will serve: Residence Commercial OtFrer �% 1 Number of living units: _Z_ Number of bed oms Character of soil to a depth of 3 feet: Water table depth F' SEPTIC TANK ❑ Type/MfgC' ----' •Capacity No. Compartments PKG. TREATMENT PLT. ❑` `� i Meth6dI of lDisposal Distant to nearest: Well r- ' ' -Foundation Property Line• fd LEACHING LINE R' No.1& Length of ii esTotal length/size FILTER BED ❑ Distance to nearest: 1Wall Foundation Property Line SEEPAGE PITS ❑F Depth ✓ - Size X �iS Number SUMPS s _/ Property DISPOSAL PONDS ❑ �e f ; 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. ` _ '" ; - _ ,.._k, f - Home owner or licensed agent's si nature.cSr'tifies;the following: j g g g: "I certify that in the performance of the work for— 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 certifies the following: "I certify that in the performa-m-c of-the work far-which41iis permit is issued,I shall employfpersoris subject to workman's compensa- tion laws of California.'_ The applicant'mu call for all-r ire `inspections. Complete drawing!n'reverse pi t Signed Title: , 3 Date:/ FOR=SE ONLY t t Application Accepted by Date 4 Area /D__ Pit or Grout Inspection by �E Date T Final Inspection by 1 T Date1J/e Additional Comments: I t t ❑ 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 CK 41FEE i c. INFO AMOUNT DUE< AMOUNT REMITTED CASH RECEIVED BY° DATE PERMIT'NO. + EH 1324 JAEV.t i k 5r - ~"10 C�oL 7/ EH 14-26 - tea.,. _ fi1•. moi- ..� e. �... - .. .. ._,..� � - *