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APPLICATION FOR PERMIT r�JU ' M SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA t 3 I A/*" Telephone (209) 466-6781 ` j 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 andlortinstall the work herein described. This application is made in compliance with San Jbaquin-County Ordinance No. 549 for sewage or No. 1862 for wMi/pump and the Rules and Regulations of the San Joaquin Local Health District. 01 Job Address � Sf /� y�/T t �l_ l _ City Lot Size [?L9 PM Owner's Names i/ [//�/�C Ste" Address '� ►¢- /A� . f► Phone aD ' 8.3 Oz's//� fG76 ��5�� C-�j his ` Conlractar /, �fGlEidress License fVo. �Phone TYPE OF WELL/PUMP: NEW WEL _ WELL REPLAC9 MENT ❑ DESTRUCTION ❑ I w PUMP INSTALL.ATIO SYSTEM REPS❑ OTHERv11 DISTANCE TO NEAREST: SEPTIC TANK �' SEWER LINES, DISPOSAL FLD. PRO . LINE j FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL^ PROBLEM AREA CONSTRUCTION SPECIFICATIOYS i ❑ Industrial ❑ Open Bottom ❑ Manteca pia. of Wel! Excavatio ___ Dia. of Well Casing of A Domestic/Prime A Gravel Pack _ X Tracy Type of Casing � Specifications S� # i`l Public-' I C1 O�her ❑ Delta Depth of Grout Seal Type of Grouj% 7af I Irrigation CW-Approx. Depth I 1 Eastern Surface Seal Installed by _ ti i Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 \' Depth Filler Material (Below 501 { TYPE OF SEPTIC WORK: NEW INSTALLATION 1,1 REPAIR/ADDITION Ll- DESTRUCTION I 1 lNo septic system permitted if public sewer is r a available within 200 feet.) { 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 PKG. TREATMENT PLT. ❑ t Method of Disposal -Distance to nearest: Well Foundation Property Line f LEACHING LINE ❑ :.No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I Depth Size Number SUMPS ❑ ;Distance to nearest: Well . Foundation Property Line k DISPOSAL-PONDS' .._❑�a'�"" ""_-�;- -�.. f. �__' ► � �_� ,. _ ...-�- _" 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 l 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 m call for all pections. Complete drawing on reverse side. 169 Signed X Title: � /y'—s Date: / T FORD ARTMENT USE ONLY k ' Application Accepted by 11 Date Are?<•' _0 L Pit or Grout Inspection by<I- Date/ y� Final Inspection by Date c� Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 l Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bo)r2009, Stk., CA 95201 f INFO AMOUNT DUE AMOUNT REMITTED C SH RECEIVED BY DATE PERMIT NO. 1 C� + EH 13-24(REV.F/k5) r EH 1428