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APPLICATION FOR PERMIT I' SAN JOAQUIN LOCAL HEALTH DISTRICT PAYMENT I 1601 E. HAZE T ON AVE., STOCKTON, CA RECEIVED Telephone (209) 466-6781 !A N 3 0 190 �J PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SAN JOAQUIN COUNI TY (Complete in Triplicate) P LIC HEALTH SI;MCES Application is heieby made to the San Joaquin Local Health District for a permit to construct and/or installF 'Nr AkMtl ff 6$1kI tion 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. Job Address f P Ina City J I L7 Lot Size PM w o- 1 F Phone Owner's Name 'e Address Contractor:&j Address-POOk-$1 7-10 License No. ✓r G6�Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT LlDESTRUCTION 171 PUMP INSTALLATION D SYSTEM REPAIR Eii- - OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. POOP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS --_—_ .INT€NDED.USE f YP� OF,WELL��^ PROBt-E(ul AREA .CON SIAUCT.ION_SPECIEICAT-IONS. _ - z ❑❑� Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing R16.mestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications l'1 Public ❑ Other II 171 Delta Depth of Grout Seal pe of Grout I I Irrigation --.-Approx. Depth i I Eastern Surface Seal Installed by - Repair Work Done E2 Type of Pump H.P. State Work Done r n Well Destruction ❑ Well Diameter Sealing Material Stop 501 oma, Depth " Filler Material {Below 501 - TYPE OF SEPTIC WORK: NEW INSTALLATION 1:1 REPAIR/ADDITION LI DESTRUCTION I I (No septic system permitted if public sewer is 11 available within 200 feet.] A Installation will serve: Residence_ Commercial_ Other !Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth '3 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments r PKG. TREATMENT PLT. O s Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size i FILTER BED ❑ Distance to nearest: Well Foundation Property Line 1 SEEPAGE PITS l I Depth Size Number I SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 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." • !i The applicant t call for all r uired i pections. Complete drawing on reverse side. Signed X Title: i ' _ Date: OR DEPARTMENT 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 4 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO /\�l r //� 'a +.EH 13-24 1 REv.1/H 5) ��oo S q Y, ""7 `l p C) - EH 14-2e Y 4