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CIN APPLICATION;FOR PERMIT SAN JOAQUINA;I0CAL HEALTH DISTRICT 1661 E.,HAZE'"TON,AVE.I STOCKTON, CA 1 Telephone (209) 466-6781 : ! , .r, I.!; l.�1 i. .. tg':i--t {'. -'.._-.t'3{..- .-. r...tel". PERMIT EXPIRES.,1,'YEAR FROM.BATE.ISSUED' u sif ai '14i Wkt3 u L�j Y �r'EF?L �. , �1t.rs r:-(Complete In Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work her6ln'described. This application is medevin compliance with,,San-Joaquin County-Ordinance No-^549.for sewage or No.-18U for well/pump and the Ruies'andlflegulations of the San Joaquin Local Health District s w, l,1 . V, a 'A0t oifli v4t s.:4� - M TZ" 't,,, q S, Tn :;ij s '. di. �� :C orf f,��.-t�' ", ,/ 7'r��1-a �if� �- Job Address 7-, T s City Lot Size. " PM a hY — : _ , Owner's Name c f1��4` iddress 7' 1 L � �S�C Phone J. Contractor's Namer se No- Phone ;TYPE OF'WELL/PUMP:; NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ PUMP INSTALLATION'❑ SYSTEM REPAIR ❑ OTHER ❑ i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS t INTENDED USE € TYPE OF WELE: PROBLEM AREA CONSTRUCTION SPECIFICATIONS II ❑-Industrial ❑ Open Bottom D Manteca - NO, of Well Excavation Dia. of Well Casing + ❑ Domestic/Private I ❑ Gravel Pack ❑ Tracy Type of Casing j Specifications ❑ Public" ❑ Other ❑ Delta Depth of Grout Seal, Type of Grout ❑ Irrigation ( 4 4pprox. Depth I] Eastern Surface Seal Installed by Repair Work Done L' Type of Pump H.P. State Work Done r Wail Destruction Llf. Well Diameter Sealing Material (top 50'1 Depth Filler Material (Below 50'1 I TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ :REPAIR/ADDITION ❑ DESTRUCTION ❑ INo septic system permitted if public sewer is ; available within.200 feet.) Installation will serve: t Residence, Commercial, Other Number of living units: i -Number-of bedrooms Character of,soil to a depth of 3 feet: Water table depth SEPTIC TANK.ii : El Type/Mfg Capacity �6a� No. Compartments PKG. TREATMENT.PLT. 0 4 r Method of sal �- _ Property Line Distance to �earest: Well `�� Foundation � LEACHING LINE {VJ( No. & L'ength of lines Total length/size FILTER BED ❑,Distance to nearest} Well I f0 Foundation V%0 Property Line_ • SEEPAGE PITS Depth f Size ' Number SUMPS 0 Distance to nearest'' 'Well Foundation Property Line DISPOSAL PONDS ❑ ` --.,I 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 , - certifies the foilowing:"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 must call for all r red inspection*. Complete drawing on reverse side. Signed Title: ��` / '� Date: 7h K v ART ENT USE ONLY 7 Application Accepted by Date Are ` Pit or Grout Inspection by �ate —/Jo Final Inspection by - Date Additional Comments: ❑ Stk 466 6761 ❑ Lodi '389-3621' t - ❑ Manteca 823-7104 ❑ Tracy 8354M Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. ;Box 2009,+Stk., CA 95201 FEECK INFO AMOUNT DUE r AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'N0. '+ EH 1524 MEV.1e/03' EH 14-28 i _ 1