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y5 , yl APPLICATION FOR PERMIT � 1 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA ! Telephone 120 9) 466-67$1 E PERMIT EXPIRES TYEAR FROM DATE ISSUED t (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. i882 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. A� Job Address /�' City Lot Size � PM L T"-Owner's yName Address Phone •1+--.:.., '�..��„�.. _ 1A� � Q X72 Contractor 'Address License No. Phone TYPE OF WELL/PUMP: NEW ELL•❑ ', LL_REPLA MENT ElDESTRUCTION`❑ PUMP INSTALLATION ❑ SYSTE� REPAIR-0- OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LI ES DISPOSAL FLD:••- PROP. LINE FOUNDATION AGRICULT R WELL OTHER WELL 'PITS/SUMPS-- Y INTENDED USE y �TYPE OF WELL PROBLEM"AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑.Open Bottom ❑ Manteca' Dia., of Well Excavation Dia. of Well Casing ❑ Domestic'/Private'' �'❑ Gravel Pack ..g XE Tracy Type of Casing• Specifications ('7 Public ❑ Other '•. -❑ Delta Depth�of Grout Seal, Type of Grout _ I I Irrigation -Approx. Depth I I E stern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. r` r, t State Work Done Well Destruction ❑ Well Diameter Sealing Material Etop 50') D_epth Filler Material (Below 501 I TYPE OF SEPTIC WORK,, NEW INSTALLATION e7l REPAIR/ADDITION I 1 DESTRUCTION I 1 (No septic system permitted if public sewer is ` available within 200 feet.) Installation will serve: Residence_ Commercial_ ther Number of living units: Number of bedrooms f Character of soil to a depth of 3,feet: v Water table depth 'E SEPTIC TANK' ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal'~ + Distance to nearest: Well 2 oundation Property Line V V' " + 16 1>4 00 I �`- E LEACHING LINE LI No. & Length of linesTo a length/size + FILTER BED ❑ Distance to nearest: ell oundation Property Line v SEEPAGE PITS f I Depth Size _ Nup,&, E SUMPS Ll Distance to near t: Well oundation Property Line f 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 Di§trict. -# 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 compensa- tion laws of Calif rnia." Theapplicant m cU for all r red inspe tions. Complete drawing on reverse side. n Signed X Title: [ J!w 1"?t 0 if Date: ! r41 � FOR DEPARTMENT USE ONLY Application Accepted by ' _Date (�"' Area Pit or Grout Inspection by Data 26__-'2- Final Inspection by � -�L Date/ 7 Additional Comments: �M ❑ Stk 466-6781 E7 Lodi 369-3621 0 Manteca 823-7104 ❑ Tracy .835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave„ P.O. Box 2009, Stk., CA 95201 IFEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PJERMIT'NO. +.Eli 13-24(REV.,/x 5) � f ��. 17-09 `,_„�� EH 14-26 [ + [