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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL I ON AVE., STOCKTON, CA Telephone (209)-466-6781 PERMIT EXPIRES YEAR`FROM DATE ISSUED (Complete in!'Triplicate"-) 1 �f ° 3< .. 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 Ryles and Regulations of the San Joaquin Local Health District. ,j 1j " F �. ' City Lot Size PM Job Address * "�_ ) - •'="�--Phone Owner's NamAddress e v Addres +•Qr� License N Phone C$ntractor- n,'� � s t NEW WELL ❑ WELL REPLACEMENT El DESTRUCTION ❑ TYPE OF WELL/PUMP: PUMP INSTALLATION '❑ SYSTEM REPAIR.❑ OTHER C3 �,. �s+kt; DISPOSAL PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ti* FOUNDATION AGRICULTURE WELL' 7! OTHER WELL PITS/SUMPS w � INTENDED USE TYPE,OF WELL PROBLEMAREA CONSTRUCTION iSPECIFICATIONS f '� L7 Industrial.�-�--�--�-----❑'OpeniBottom'� -�P- Manteca.,,,- -„ -_Dia. of Well.Excavation Dia. of Wel! Casing W '� Type of Casin �1 J 1`�t� Specifications 4- ❑ 11Pa Domestic/Private Gravel ck ❑ Tracy 9 y =...t r _ x -. _h :_ - Type Grout -� © Public ❑ Other,: ❑ Delta” Depth of Grout Seal• - ❑ Irrigation —Approx. Depth ❑ Eastern Surface Seal Installed by _H.P. y state Work Done Repair ' Wpe of Work Done�❑ TyPump _ €.ts Well Destruction ❑ Well Diameter Sealing Material.(top'"50') - :. ► ;. 4 ' 'k- `Filler Material (Below 50') $ I Depth" ' tem permitted ifpublicsewer is TYPE OF SEPTIC WORK;. NEW INSTALLATION ❑ REPAI ADDITION DESTRUCTION❑ alvailablelwthin 200 feet.) p Installation will serve: Residence Commercial -Other- Number of living units: Number of bedrooms ` I Character of soil to a depth of 3 feet: � - Water table depth. � ; ► r� Capacity No. Compartments SEPTIC TANK ❑ Type/Mfg4 I ,.,{..._.. , -- Method of Dispbsal'----'-"`r ""T`" PKG. TREATMENT PLT. ❑ Distance to nearest: Well Foundation Property Line LEACHING LINE No. & Length of lines I "' � 1 �otaf length/size FILTER SED ❑ Distance to nearest: Well/ t t Foundation 0o #' Property Line—.....a-,.,..-».•.__ SEEPAGE PITS Q Depth Size 'P,/N.uum�ber 1 m SUMPS Distance to nearest: Well t* Foundation_ r r� •" Property Line 'f"' DISPOSAL PONDS Q ! 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 Joaquiri,,Local Health District. Home owner or licensed agent's signaidre certffies the following: "I certify that in the performance of the work for which this permit is issued, I steal!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." The applicant st call f requ' Complete drawing on re a .I de. . 1 Signa 7 Title: Date: ed _ FOR DEPARTMENT USE ONLY _ �.� r.-S Area � �-- --.,-�-•...--,."-„".'�..`_ Date ,v Application-Accepted'by""""" - Date Date Final lnspectib on; y Pit or Grout Inspection by r .' b � f � B•ii 2 i Additional Comments. j,,� ' dp p Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy `5-6385 jOCc� U►N o a� �'^"B Ae'Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 1 ?p rA 15 . 'A.eu-y to 4!e � • CK# RECEIVED BY DATE PERMIT NO. FEE INFO AMOUNT DUE AMOUNT REMITTED CASH `7 ass 2� r + EH 13-24 1REv- /s 51 ,�•,� — EH 1426 - - V