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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 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 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 the San Joaquin Local Health District. Job Address ! �ds/�/L/ City Lot Size _ PM Owner's Name(.r a WWA Address Phone Contractor L-i lA� - ddres's ' License No. "Aj� PhoneXOOZU TYPE-OF WELL/PUMP NEW-WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ _ A, DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PF40BLEM AREA CONSTRh(CTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑Wanteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack__ _ ..,❑:Tracy_. Type of Cesing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation _—Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Ddne., Well Destruction ❑ Well Diameter Sealing Material (top.50') Depth Filler Material (Below'W7 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is ��II available within 2_00 feet-) Installation will serve: --Residence n Commercial_ Offief Number of liyling units:--/-- Number of bedrooms Character of!!,soil to a depth of 3 feet: A5Af7r AE Water table depth (� SEPTIC TANK 11Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LI ❑ No. & Length of lines Total length/size FILTER BED 1 ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth AS Size,!si� �C��Y e�J��,� Number TY SUMPS �d 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"fM following: "I certify that in the performance of the work for which this permit is issued, I shalt not , employ any person in such manner as to become subject to workman's compensation laws of'California."Contractor s'hiring or sub-co tracting signature certifies the following:"I certify that in the performance'Of She work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." The applicant call for all required i pectio . Complete drawing on reverse side. Signed Title: Date: FO DEPARTMENT USE ONLY t lication Accepted by Date r— Area Pit or Grout Inspection by rate 0L—I :O}Final Inspection by Date 3� � Additional Comments: I ❑ Stk 466-6781' ❑ Lodi 369-3621 ❑ Manteca M7104----"CTTracy_ 835-6385— Applicant- Applicant.-Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT N0. INFO n CASH tt + EH 13-24(REV.1/65) (�"_ 7 -IC7 EH 14-26