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i1 .. APPLICATION FOR-PERMIT SAN JOAQUIN LOCAL.HEALTH DISTRICT 1601 E. HAZEL T ON AVE., Q STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DEC 6 11 $$ i� (Complete in Triplicate) Application is hereby made to theSan Joaquin Local Health District for a permit to construct and/or install the work herein�deScri6ed FThisi application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and F�apufiatib�is MAe"Wn Joaquin Local Health District. ! y� :T � Job Addres �✓ �!a�... D ••- City at Size PM 4 Owner's Name' �i(?-Z Address �i� .w/1, Phone Contractor AddresAOLs G License No. Phone TYPE OF WELL/PUMP: �I NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR Pr OTHER ❑ R� _ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES' DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial ^- ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing. 3womestic_/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications "f] Public n Other F- Delta Depth of Grout Seal Type of Grout _ I I Irrigation Approx. Depth I Eastern Surface Seal Installed by Repair Work Done W Type iof Pump [i H.P. State Work Done Well destruction ❑ Well Diameter Sealing Material (top 50') t 0 y - Depth Filler Material i8elow 50')- # ' TYPE OF SEPTIC WORK: NEW INSTALLATION Ia REPAIR/ADDITION (:I DESTRUCTION I I (No septic system permitted it public sewer is available.within 200 feet.) Installation will serve: Residence Commercial— Other t Number of living units: i Number of bedrooms Character of soil to a depth of 3.feet: Water table depth SEPTIC TANK - ❑ Type/Mfg 1 Capacity No. Compartments > PKG. TREATMENT PLT. © i3' f Milthod of Disposal Distance to nearest: Well Foundation Property,Line LEACHING LINE ❑ No. & Length of lines " o-'1 Total length/size " FILTER BED 11Distance to nearest: Well FFouridation Property Line SEEPAGE PITS I I Depth Size Number + L f 'SUMPS LlDi"stance to nearest: Well � -Foundation Property Line -T DISPOSAL PONDS . ❑ I hereby certify that I have prepared this application and that 16work 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 f 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." t The appf mu call for all req inspe ons. C lets drawing o verse side. Signed.X Title: ffI Date: i! FOR DEPARTMENT USE ONLY 'q Application Accepted by �._ Date ` Area ` Pit or Grout Inspection by !.C` Date Final Inspection by Date% a Additional Comments: ❑ Stk 466-6781 - L7 Lodi 01.369-3621 ❑ Manteca 823-7104 '❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 CK FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. +.EH 13-24 1REV.1/x 5) '�'��`�'r EH 14-29i_:J �