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APPLICATION FOR PERMIT r �A SAN JOAQUIN LOCAL HEALTH DISTRICT a ' C Em 1 7 ; k`i 2 1601 E. HAZELTON AVE., STOCKTON, CA SEP � � 9�� Telephone (209) 456-67$1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED_ ENVIRONMENTAL HEALTH (Complete in Triplicate) - PERMIT/SERVICES 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 I 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. Job Address L4 � ""-tet City Lot Size PM Owner's Name AddressPhone ' Contractoddressafy /6, 9-_'Z10 License No. �2 -Phone — F r TYPE OF WELL/PUMP: NEW WELL ❑ WELL-REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION 4.1� SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE r- FOUNDATIONt ---� AGRICULTURE WELL --OTHER-WEL-L---T -- PITS/SUMPS_-= INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS [' ❑ Ind Tial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Zf omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F] Public F1Other F1 Delta Depth of Grout Seal Type of Grout _ ' I I Irrigation ..r..Approx. Depth I I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 G Depth Filler Material (Below 501 -- r TYPE OF SEPTIC WORK: -NEW INSTALLATION i I REPAIRlADDITION I ) DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) P rte► Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Ch-wacctter of soil to a deptl�'of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments 60 PKG. TREATMENT PST:❑ " -„- �- Method-of Disposal 4 i1 Distance to nearest: Well, Foundation Property Line LEACHING LINE ❑ No. & Length of lines 4 Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line I i SEEPAGE PITS l 1 Depth Size _ Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS' ❑-,r —' -'r 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 Dt%trict. 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 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 compensa- tion laws of California." 1 The applicant must call for all required inecti ns. Complete drawing o e arse -side.', Signed X Title: Date: y oZl o I I FOR PARTii11lENT USE ONLY Application Accepted by Date D� O Area Pit or Grout Inspection by Date Final Inspection b Datl�*04 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/-Ser-vices.1601 E.Hazelton Ave., P-O. Box 2009, Stk., CA SS201 FEE AMOUNT DUE AMOUNT REMITTED CK 4 RECEIVED 6Y DATE PERMIT'NO. INFO CASH r.EH 13-24(REV.IrRS) M. 111A 900` EH 14-26