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APPLICATION FOR PERMIT I SAN JOAQUIN LOCAL HEALTH DISTRICT T �•„ . .. ._. - 1601 E. HAZELTON 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. J Job Address City Lot Size_ J ._�� PM f � Owner's Name Address 3,29.6-67 13 Phone r r. , Contractor A, Address Y i 6 z /�/S� �%�� License No.n' �5c5�'oZPhone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ j PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER I-INES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS D Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy a -Type of Casing Specifications M Public Cl Other t F Delta Depth of Grout Seal Type of Grout 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 Itop 50'1 Depth Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION I'1 REPAIR/ADDITION DESTRUCTION l 1 INo septic system permitted it public sewer is N available within 200 feet.) ,f Installation,will serve: Residence Commercial 'Other'. } f Number of living units: -IL— Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK 17Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ I F �- �" Method of Disposal Distance to nearest: Well Foundation Property Line ,fry- , LEACHING LINE No. & Length'of lines.�2 Total length/size d �~ FILTER BED 1-1ea Distance to nrest: Well Foundation S�2Lf . Property Line l Z SEEPAGE PITS [ I Depth �`5 Size' /x - Number w SUMPS _ Distance to nearest: f. Well. A?el' �o dation W Property Line DISPOSAL PONDS ❑ Ir herdby certify tKit I have prepared this`application and that tKe work-wilf be'done in acc&darlce with San Joaquin county ordinances, state taws, 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 following: "I certify that in the performance of the work for Which this permit is issued,I shall employ persons subject to workman's compansa tion laws of California." - The applicant must call for all requir d inspections. Complete drawing on reverse side:-- Signed X Title: Date: y, t FORD ARTMENT USE ONLY Application Accepted by ` - Date Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466.6781 0 Lodi 369-3621 ❑ Manteca 823-7104 0 Tracy 835-6385 ' Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. -Box 2009,Stk., CA 95201 FEE AMOUNT DUIE AMOUNT REMITTED CK RECEIVED BYpATE�a,...... ,P.ERMITrNO.� a INFO - -OASH-r'- —T — �_ f' ♦.EH1 -141REY.i/Hsl qs� EH 144-28 '