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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone, (209Y 466-6781 PERMIT EXPIRES 1'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. 6 ' �? ress Jab Add7 /Y1 f City Lot Size PM Owner's Name Contractor's Name Address ::!�A-444 ` Phone 13311-32 8 License No. WELL REPLACEMENT ❑ DEST SYSTEM REPAIR ❑ LINES DISPOSAL FLD !LTURE WELL OTHER WELL_ TYPE OF WELL/PUMP: sI NEW WELL ❑ PUMP INSTALLATION ❑ DISTANCE TO NEAREST: SEPTIC TANK I �S FOUNDATION A INTENDED USE 0 In,�o 4strial LIDbitestic/Private ❑ Public tt:f ❑ Ire'iga ion Repair Work Done ❑ Well Destruction ❑ Phone4*02( - ICTION ❑ OTHER ❑ PROP. LINE: PITS/SUMPS TYPE OF WELL PROBLEM AREA'- CONSTRUCTIONpSPECIFICATIONS ❑ Open Bottom ❑ Manteca Dia.,of Well Excavation ❑ Gravel Pack ❑ Other ❑ Tracy Type�of.Casing ❑ Delta Depth of G out Seal -�lpprox. Depth Type of Pump ❑ Eastern Surface Seal Installed by H.P. State Work Done _ Well Diameter Sealing Material Itop 50'1 Depth Filler Material (Below 501 Dia. of Well Casing Specifications ; Type of Grout t TYf?F SEPTIC WORK: NEW INSTALLATION ❑ REPAIRlADDITION, DESTflUCTION LJ (No septic systi3m`perrriittei available within -200 feet.) ,Installation will serve: Residence )� Commercial _ Other Y i _ Number of living units: Number of bedrooms 3 .•-70 - # �" Character of soil to a depth of 3 fest: A� --V! Water table de$th — SEPTIC TANK E:1Type/Mfg __Capacity No. Compartments PKG. TREATMENT PLT. ❑ '"fc .t I/r � J Method of Disposal " is j y -PropDistance-,to nearest:1.5,Well Fouridation erty Line , +" �.-,`" : .---- Total length/size LEACHING' LINE;v No. &_Length of liness�/ ` a. -.- ,�r„ ` '�, _P.ropertymLine. �� a FILTER BED ., l❑ DistanEe•to-nearest Well .-`Foundatic5n� - e i -2;K-57 .- 1 Number 1 SEEPAGE PITS � Depth �:S Size _ A- , v ; ,f, SUMPS ❑ 'Distance to nearest: )Nell � Foundation Property Line # DISPOSAL PONDS c' !❑ I hereby'b'ertihat I -have prepared this application -and -that the-work.will_be -don a in accordance -with -San Joaquin county-oldinances, state laws, and ify rules and regulations -of the San Joaquin Local Health District. Home owner or`licens&d'agent's signature certifies the following: "I certify that in,the performance of the work for which this permit is issued, k shall not employ a'ny person in such manner as to became subject to workman's compensation laws of California." Contractor's hiring or sub -contracting signature certifies:the follow g: "I certify that in the performance of th6-.work.for wFiich this permit is issued, I shall employ persons subject to workman's compensa tion laws of Cali mia."' I The applica .s st all for all r fired ins tions. Complete drawing n raver t fide. i j Sig ed `I { T T Title: Da . "FOR DEPARTMENT USE ONLY X r' _ f jr IV f r,a s i Area if public se f 4- "?- 1? , S 4 C Application Acceptedtby -- - . , ' .r'� Final Inspection by -.� XPi or Grout,Inspection by f •" �er Additional Comments: ❑ Stk 466 6781 ❑ Lodi 369-3621 ❑ Manteca 823-7144 ❑ Tracy 835 -SM —Applicant,- Return,all-copies"to:_Environmental -Health .P_ermit/.Services 1fi0�-E.Hazelt ve.,-P_.O..Box'2409, 5tk.,_ '7 FEE_ AMOUNT DUE— —AMOUNT REMITTED-� CASH �lncccw�� p. - � -• - -" INFO- p } 'S + EH 13-241REV" 107835 EK 1426 " -1