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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 TYEAR 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. � C Job Address 1"` ©S�m t�� City j'C Lot Size PM Owner's Name Address Phone Contractor ,J _.- CA"(O'_ Address � � . V � �� License No. 391Y Phone �2-� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT LI DESTRUCTION ❑ _ i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 ❑ Industrial ❑ Open Bottom © Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ("1 Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation --Approx. Depth I 1 Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 ✓ b a Depth Filler Material (Belo 50') TYPE OF SEPTIC WORK: NEW INSTALLATION Ll REPAIR/ADDITION IW' DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Clb Installation will serve: Residence— Commercial_Z Other Number of living units: ' Number ofdrooms t Character of soil to a depth of 3 feet: 26N�� I Water table depth r SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 0 _ _ Method of Disposal Distance to neatest: Well Foundation Property Line f, LEACHING LINE ❑ No. & Length of lines + I t Total length/size _ FILTER BED LKDistance to_nearest: Well Foundati n Ira Property Line SEEPAGE PITS 1;1 Depth Size _ Number p r SUMPS ❑ Distance to nearest:. Well Foundation Property Line �Y DISPOSAL PONDS ❑ hereby certify that I have prepared this application andFthat 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.becorne subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the pe rmance of the work for which this permit is issued, I shall employ,persons subject to workman's compensa- tion laws of California." + a _ The applicant must call for all required-ins tions.-Complete drawing on reverse side. ---- --- Signed X � `Title: C.J1)o e,4— Date: , d ' OR OEPARTMENTtUSE ONLY f Application Accepted by i Date Arae Pit or Grout Inspection by .Date z Final Inspection by Date Additional.Comments: I ❑ Stk 466-6781 ❑ Lodi !369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 f Applicant Return..all"copies to:rEnvironmental_Health.Permit/.Services-1601—E.-Hazelton Ave., P.O: Box 2009,-Stk,-CA-95201.«-FEE --�+ N119 INFO AMOUNT DUE ,,,AMOUNT REMITTED DA'SH`'`/ RECEIVED BY DATE PERMIT-NO, + EH 1 -24iREV.1/H51 �� ! ► 1� �� a C11/J / � / „(„\ U� EH 144-28 IIIJJJ rr' TTT (r+. ✓✓17" (/ L]