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• 1. E APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT r 1601 E. HAZELTON AVE.,,STOCKTON, CA - Telephone {209) 466-6781 t PERMIT EXPIRES 1 YEAR FROM.DATE.ISSUED., _,,1.j,,'0„1t(Complete.in rTriplicate) ,.I0 Z.000500;br4 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. y Job Address 5 City Lot Size t/ 0 PM ., . .. Owner's Name ddress l S Phone 7 �r g'1 �'] I Contractor License No. _ v-`-�Phoner 7� / 3 TYPE OF WELL/PUMP: ifl NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL'FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL C: 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 ❑ Public ❑ Other ❑ Delta' Depth of Grout Seal a Type of Grout ❑ Irrigation 1 ( Approx. Depth ❑ Eastern a Surface Seal Installed by y - Repair Work Done Type of Pump H.P. - State Work Done Weil Destruction ❑ Well Diameter Sealing Material (top 501 y Depth ' Filler Material (Below 501 i TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is -g' I tavailable within 200 feet.) Installation will serve: Residence Commercial Other Number of living units: Number of edroo s-��_ t 1Ltl�� Character of soil to.a depth of 3 feet: Water table depth ��” U 1 SEPTIC TANK r .C7 Type/Mfg ' Capacityi No. Compartments PKG. TREATMENT PLT..O_. i ... Method of Disposal t Distance to nearest: Well P"OW O Foundation. Property Line LEACHING LINE LJNo. & Length of line, ai Total length/size ` FILTER BED ❑ Distance to nearest: Well Foundation o erty Line"" SEEPAGE PITS ; ❑ Depth Sizem er _ ' SUMPS ;❑ Distance to nearest:- Well Foun ation +JIfAlt Property Line S i rDISPOSAL PONDS s❑ ` ` 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." 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-" „ The applicant must call for ail requir d inspections. Complete drawing on reverse side. 'P 4 Signed Title: /� Date: -3-3 i U t FOR DEPARTMENT USE ONLY Application Accepted by Cir Dated 0 Area Pit or Grout Inspection by ' r Date))__ 'g'� Final Inspection by Data `� Additional Comments: FAI 1 7t1 i14-10 t 1 t -. d rap JL l l ❑ Stk 466-6781 ❑ Lodi 369 1 it Manteca 8237104 ❑ Tracy 835-6385 1bLi �2� f Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., A 95201FEE y I INFO AMOUNT DUE AMOUNT REMITTED CK f CASH RECEIVED BY DATE PERMIT'NO. �7 F f .+ EH 124.,IAEV.1,/h 51