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APPLICATION FOR PERMIT ' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA S w Telephone (209) 466-6781 �� m� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED $, �ypC�2�a• (Complete in Trjplicate) W 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 A 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- e1�� rYa afar bhr� t^uno� �rL�taL 1?/ / rL6fCFJ Cit Lot Size PM Job Address �} G \ / + �� Lf�lGe[?Z! Address ° ' Phone X owner's Name i -6d� Address f — License No. Phone Contraclar - TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Y; PUMP INSTALLATION ❑ SYSTEM REPAIR.O OTHEA ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f Q Industrial ❑ Open Bottom L Manteca Dia- of Well Excavation Dia. of Well Casing A ❑ Domestic/Private ❑ Gravel Pack '❑ Tracy Type of Casing Specifications ['i Public [_7 Other 'l Cl Delta 5 Depth of Grout Seal Type of Grout ( I I Irrigation --Approx. Depth Li Eastern = "' Surface Seal installed by - N Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material ltop 501 Depth Filler Material (Below 50') fi r'' TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I 1 DESTRUCTION I I (No septic system permitted if public sewer is �} available within 200 feet.I 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 * ' SEPTIC TANK' ❑ Type/Mfg Capacity No.'Compartments,Y. ' �. PKG. TREA7MENT.PLT. 11 Method of Disposal- j.. Distance to nearest: Well Foundation w Property.Line LEACHING LINE ❑ No. &Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number 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, aro f I rules and regulations of-the San Joaquin Local Health Diltrict. 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: "1 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." The applicantst call for all r/"j utred�inspections. Complete drawing on reverse side. �( Signed X fes' � 16. c Title: Date: L\ �. FOR DEPARTMENT US ONLY Application Accepted by _ ' M Date rea Pit or Grout Inspection by Date Final Inspection by Date07 ✓ Additional Commeryt t ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 3-7104 ❑ Tracy 836-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i r FEE AMOUNT DUE AMOUNT REM1TTEl] ASH RECEIVED BY GATE PERMIT NO. INFO /�. • EH13-24IREV.Vm51 4 EH 14-26 _