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�.c�,,,�;� � x-12 GS d�•...,�-(-c APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT , 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209!1466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED x. f - „ (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. qyJJob Address O n City Lot Size x PM ��, A r - ddress I` /� Phone Owner's Name - Contractor Address _ _ License No.. _ Phone - TYPE OF WELL/PUMP: NEW WELL`❑ WELL REPLACEMENT I-] DESTRUCTION ❑ PUMP INSTALLATION 171SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 'A 4 '' SEWER LINES DISPOSAL FLO. PROP. LINE s FOUNDATION AGRICULTURE WELL OTHER WELL_ PITS/SUMPS,: — INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation f Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing _ Specifications ❑ Public ❑ Other C1 Delta E. Depth of Grout Seal Type of Grout t ! ❑ Irrigation ---Approx. Depth El Eastern Surface Seal Installed by r Repair,Work Done ❑ Type of Pump H.P. State Work Done - ; �J Well Destruction ❑ Well Diameter Sealing Material {top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION D TRUCTION ❑ (No septic system permitted if public sewer is avail le within 2 feet.) f� Installation will serve: Residence_ Commercial_ kOthe� Number of living units: Number of bedrooms / t }' Character of soil to a depth of 3 feet: 1 Water table depth SEPTIC TANK LlType/Mfg Capacity No. Compartments r PKG. TREATMENT PLT. ❑ 4 rMdthod of Disposal " Distance to nearest: Well, Foundation Property Line: 'f LEACHING LINE ❑ No. 8� L g h of lines_ Total length/size' �u FILTER BED EJ- Distance to nearest: Well Foundation PropertyNLine € ' SEEPAGE PITS ❑ Depth; Size{ 's° Number s SUMPS ❑ Distance to nearest-. Well ' ",Foundation Property Line �. DISPOSAL PONDS ❑ 1 # 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 9 9 9� ., �Y Pe � 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." r The applica ust call fo II required inspections. Complete drawing on reverse side. ; Signed I Title: &122nnICA Date: ' j P FOR DEPARTMENT USE ONLY 'f f i Application Accepted b Date 2 Area i Pit or Grout Inspec'' y ' - Date Final Inspection by Date �� Additional Comments: ❑ Stk 1466-6781 ❑-Lodi.-369-3621—D-D-Manteca•-8234104—0-Trady-835:M 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 a -CK ` RECEIVED BY DATE PERMIT'NO. INFO CASH + £H t324(REV.1/851 � /�v �—� 0 /'�� EH 1426 L i P `