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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEI_TON AVE., STOCKTON, CA Telephone {209) 456-6781 ° 4 PERMIT EXPIRES TYEAR FROM DATE ISSUED t;• (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 then Joaquin Local Health District. City Lot Size PM Job Address Phone flww//r1 LA.)1P Address Owner,s,Name .s — '` L icensg_No. Phone -40^f Conttac or _ Address DESTRUCTIO 1 !TYPE,OF,WELL/PU NEW WELL ❑ WELL REPLACEMENT ❑ pU TALLATION ❑ SYSTEM REPAIR ❑ OT ~� PROP.LINE SEWER LINES FLD. tDISTANCE TO NEAREST: SEPTIC TANK qG W OTHER WELL PITSISUMPS I� FOUNDATION: ;• �, INTENDED USE TYPE OF W PROBLEM ARE NSTRUCTION SPECIFICATIONS �� " O Manteca --'t-71 Dia. of Well Casing ottom Q--- Dia. of cavation �-- t f❑ Industrial ❑ .,�; Specifications Type of,Casing,— - + 1❑ Domestic/Private ❑ Gravel Pack ❑ Tracy f ' YP Type of Grout = li ' Depth of Grout Seal t f'1 Pu ❑ Other ❑ delta blic It R iI i Irrigation --,Approx. Depth I 1 Eastern ]j A Surface Seal Installed by Type❑ e of Pump H.P.' State Work Done Repair Work Done f Sealing'Material (top 50') t i Well Destruction ❑ Well Diameter IDepth - —Filler Material (Below 50') ITYPE OF SEPTIC WORK: NEW INSTALLATION IJ REPAIR1ADt]ITIONR I I DESTRUCTION available c system per r within 200 feetjed if public sewer is #' Installation will serve: Residence Commercial— Other t r Number of bedrooms Number o i s: Water table depth � Character of soil to a ep r Capacity No. Compartments SEPTIC TANK ❑ Type/Mfg Method of Disposal IPKG. TREATMENT PLT. ❑ r , Distance to nearest: Well dation Property Line ! r { 1 _ LEACHING LINE ❑ No. & Length o1 lines I Total length/size Foundation Property Line FILTER BED EltDistance to nearest: Well ` SizeNumber SEEPAGE PITS ;` I ! i Depth `, ,_a w } t Ll Distanrce to nearest: Well Foundatibn" "P�operty L"ih SUMPS I i DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will 11 be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health Di§trict. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this r'sub- o 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: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa i +tion laws of California." I f I The applican ust calf for all require inspections Complete drawing on reverse side. � Data: r. C f Title: Signed X FOR DEPARTMENT USE ONLY a I f j Date Area I Application Accepted by l 11 Date Final Inspection by Y j DataS J Pit or Grout Inspection i} a. I I Additional Comments: l❑ Stk 466 6781 ❑ Lodi 369-3621 C] Manteca 823-7104 1 ❑ Tracy 835-6385 Applicant Return all copies to: Environmental Health PerrnitlServices 1601 E. Hazelton Ave`, P.O. Box 2009, Stk., CA 95291 .,., ... t t FEERECEOEI?BY DATE INFO PEFtM1T NO. AMOUNT DUE �' `j'AMUUNT'ftEMITTED SH _ .�,....., +- E413- iREV.r 1 n 5) .� EH 14.26