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-:/lis ter APPLICATION-FOR PERMIT ,�. SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-67$1 F . PERMIT EXPIRES 1 YEAR 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health t A Job Address Z U }J O �ys�Ufa A �SGf/�rJN city Lot Size PM Owner's Name i c Ge Address Phone .Contractor's Name Y i`'` SOS License No. yyS! Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ { PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.,1 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 W F ❑ Public ❑ Other ❑ DeltaDepth of Grout'Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ EasternSurface Seal Installed by Repair Work Done LDType of Pump H.P. - State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50'i Depth Filler Material (Below 501 TYPE,OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ INo septic system permitted if public sewer is C Q available within 200 feet.) t � Installation will serve: Residence X Commercial— Other Number of living units: Number of bedrooms y Character of soil to a depth of 3 feet:—5Ar1191 Water table depth A� SEPTIC TANK _X Type/Mfg /5-C CA.s' Capacity No. Compartments 2- PKG. TREATMENT PLT. © Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 50 No. & Length of lines �- �� A •Total len_gth/size FILTER BED ❑ Distance to nearest: Well 170" Foundation /4Property Line SEEPAGE PITS i ❑ Depth Size Number SUMPS jk "Distance to nearest:._1 Well 190 Foundation e4 Property Line 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 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 compensa- tion laws of California." -^�^ The applicant muss II for all required inspections. Complete drawing on reverse side. Signed X dcf�7� Title: - Date: �� fOR EPARTMENT USE ONLY Area Application Accepted by.-- - Date Gc� a Pit or Grout Inspection by .�7 D e - Final•Inspection•by. Date Additional Comments, i ❑ Stk 466-8781 ❑ Lodi 369-3621 ❑ 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 1 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMI7"NO. INFO CASH e� +EH 13-24 EH 1428IREV.101831 Is b � g _119 n I