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� ;� - •car APPLICATION FOR PERMIT - SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE.,,STOCKTON, CA Telephone {209} 466-6781 _ PERMIT EXPIRES"i YEAR FROM 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin ' Local Health District."' �... Job Address ;A e- !S' �. rf a f�i i+lam` y/�C{ 'fi�rr-��,0�0 Cityck71)A.tot Size /O. AIX41 f t Owner's Name e �c7.t✓ Address _ �-��/ �G �� Phone 1 RFs k + Contractor Address License No. Phone { TYPE OF WELL/PUMP: 3 NEW WELL ❑ WELL,REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION LJOTHE SYSTEM REPAIR ❑ ' r r' DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.° PROP. LINE 4 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS { INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom If Manteca Dia. of Well Excavation§ F s•a, t'y Dia. of Well Casing ❑ Domestic/Private D Gravel Pack El Tracy Type of Casin ; § Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work„Done ! n) Well Destruction Q Well Diameter Sealing Material (tap 501 f E Depth Filler Material (Below 50') t� TE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION El INo*sepfic system permitted if public sewer is 1 �—availabie'within 200 feet.) Installation wi Residence_ Commercial_ Other Number of living units: Number of bedrooms a Character of soil to a depth of 3 fee . . I . .. Water table depth _ SEPTICITANK Elype Type/Mfg _ p C Capacity- No. Compartments PKG. TREATMENT PLT. ❑ � Method of Disposal ! �� Distance to nearest: Well �`i' ation o Property Line S 1 _ � LEACHING LINE y ❑ No. & Length of lines w - To th/size FILTER}BED ❑, Distance to nearest: Well Foundation ; Prop } } SEEPAGE PITS ' o ❑ Depth Size 1 _l Number ° SUMM ❑ Distance to nearest: Well FoundationProperty Line i DISPOSAL PONDS Q I hereby1certify that I have prepared this application and that the woek will be done in accordance-with.5an Joaquin co ty ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. t a. .x^"1 A 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 dny 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: '9 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 applicant must call for all required inspections. Complete drawing on reverse side. d e Signed Title: Date: 3 =FOR EPARTMENT USE ONLY sem..,-,....m..t..s—�.. Applicat bn Accepted by Date Pit or Grout Inspection by y Date Final Inspection by Dated 2f� 41— Addition$I'Comments: (_ 1 ❑ 5tk 466-6781 _p}Lodi 40;-1621_D Manteca-823-7104,.. IJ Tracy-835-6385�..-.� _.. .� Applicant- Return all copies to: Environmental Health Permit/Services 1661 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 y~ w 5. Wit ; r� 4,✓„ _ FEE AMOUNT DUE ' AMOUNT REMITTED CK V DATE PERMIT N0. INFO CASH 'RE D BY t EH 1324IREV.v 8 51 EH 14-28