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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 4_66-8781. , . .. PERMIT EXPIRESll FR YEAR OM 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.This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 186'1 for well/pump and the Rules and Regulations of the San Joaquin Local Health District Job Address ' �' City Lot SizePM f „Pe'le r .. y ` t' �` Phone Owner's Name Address.. - —- -A �j(� ContractorAddress/ � � � �>� License No.L_ 54379 Phone _ TYPE OF WELL/PUMP: NEW ELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ,� r PUMP INSTAL TION ❑ STEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINI DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULT RE-WELL OTHER WELL PITS/SUMPS' INTENDED USE TYPE OF°WELL PROB AR CONSTRUCTION SPECIFICATIONS " ❑ Industrial ❑ Open' Bottom ❑ Manteca Dia:of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications t i t ❑ Public ❑ Other! ' ❑ Delta De of Grout Seal Type of Grout _ t ❑ Irrigation ---Approx. Depth ❑ East n Surface I Installed by - `'• ti r 1 Repair Work Done ❑ Type of Pump H.P. State Work Dane Well Destruction ❑ Well Diameter Sealing Material {top 50') i DepthFiller Material il3elaw 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is 1 j available within 200 feet) Installation will serve: Residence Commercial -Other i Number of living units: Number of bedrooms 1 "- Character of soil to a 6epth:of`3 feet: "� N� .I Water table depth SEPTIC TANK LlType/Mfg" - Capacity No. Compartments y., 3"J PKG. TREATMENT PLT. ❑ ate` Method of Disposal -Distahce to nearest: Well ZOO Foundation 12— Property Line VA D10 Z�F # J I I LEACHING LINE L< No. & Length of lines ff) '!• i Total length/size Z 1 FILTER BED ❑ Distance to nearest: Well /DOT Foundation .20 _ Property Line p SEEPAGE PITS Depth Z �� ^. Size " Number `- ,.,�_ r. � 3 SUMPS= ' ❑ Distance to nearest: Well Foundation J Property Line DISPOSAL PONDS ❑ 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 Districf, tt +-- I % J I• 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 becorfie subject-to wdrkma6's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's comperisa---,I 'i tion laws of California." _? The applican must call fora required inspections.Xomplete drawing on reverse side. Signed Title: Date: f � FOR DEPARTMENT USE ONLY E I Applica� pGe ted by 4 k Date �3 �7 Area _ Pit or'�Qrout,lnspection y NO Date 3 3 $ Final Inspection by Date -AJ /11 7 ? `Additional Comments: _ ! ❑ Stk 466-6781 ❑ Lodi 369-5(21 ❑ Manitece r 823-71 ❑ Tracy 835.6= S 7 S Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 e r r g FEE AMOUNT DUE AMOUNT REMITTED CK AECEtvED BY DATE PERMIT NO. k �. .......�.....—/8-5) .._..-. INFO --------_..... �, -- - --- CASH .� ....,..._...T--_�j..- ----# •~ + EH 13-24 IREV.i/e 51 ��i_� ,.� EH 1426