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I I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT fir ' 1601 E. HAZEL I ON AVE., STOCKTON, CA `V.t Telephone (209) 466-6781 , f 4 PERMIT EXPIRES ! YEAR FROM DATE ISSUED t. T (Complete in Triplicate) Application is herely"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 complianc&..IWith San-Joaquin County Ordinance No.549 for sewage or No., for well/pump and the Rules and Regulations of the San Joaquin Local Health Districf Job Address f City aj Lot Size PM r Owner's Name I * - ddress �f f Phone It-;Contractor dress /� License No, �V l i Phone "✓ TYPE OF WELL/PUMP: 0 N WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ y PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTA'NC_E TO NEAREST: SIEPTIC TANK SEWER LINES DISP _ OSAL.FLD. .PROP."L•INE" �•• F ___OUNDATION L AGRICULTURE WELL I OTHER WELL PITS/SUMPS INTENDED USE- `' TLYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS e E ❑,Industrial ❑ dpen:Bottom ❑ Manteca-Q- , Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑Gravel Pack `i Cl-Tracy k T ��.: Y ype of Casing Specifications e ❑ Public EOther 'p.'pelta '`;Depth of Grout Seal Type of Grout ❑ Irrigation —Approx. Depth ❑"Easter 0'—� Surface Seal Installed by -Repair Work Done ❑ Tylp9 of Pump H.P. State Work Done I Well Destruction ❑ \4 bll Diameter Sealing Material (top 501 DBpth Filler Material (Belo 50'1 e \TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION e DESTR TION ❑ (No septic system permitted if public sewer is , ' �� - vailable w' in 200 feet.) } Installation will serve:; Residence Commercial_ Other " Number of living units: �L Number of bedrooms Character of soil to a depth of 3 feet: - Water table depth SEPTIC TANK ❑ Type/Mfg " v- Capacity-1-2--00 No. Compartments PKC. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well SO Foundation Property Line LEACHING LINE ❑ No. & Length pones Total length/size FILTER BED ❑ " Distance to r ° Foundation Pro party Line SEEPAGE PITS ❑ Depth Number ' r SUMPS El-I Distance ell Foundation Property Line DISPOSAL PONDS ❑ ..i I hereby certify that I have prepared this application and At 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."Contractors 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." ,gyp, The applic must call allrequiredinspections. Complete drawing on reverse side. f t Nil l Signed Title: Date: FOR DEPARTMENT USE ONLY Q� Application Accepted by Date � a'! Area f Pit or Grout Inspectiby on by �f Date Final Inspection Date Additional Comments: If l ❑ 5tK '4%-6781. ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8354i385 R i Applicant- Return all copies io: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 4FEE I�I INFO AMOUNT DUE AMOUNT REMITTED CKCASH RECEIVED 8Y DATE PERMIT''N0. + EF�11i724IREV.i/ssl �..�.J....�....�._.,,....�.,...{ - EH 1425 " ��r`CaO /3� IO` Q I