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APPLICATION FOR PERMIT ' ' f SAN JOAQUIN LOCAL HEALTH DISTRICT I� 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED �i f��mplete in Triplicate) I c,1 // 7 d' I Application is herby made/to the San Joaquin Local Health Distract for a permit to construct and/or install the work herein described.This application is made in compliance with S 1n�Joaquin C unty Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. a Q�S� ! Job Address _6�10ost b3 City Lot Size PM Owner's Name I�wt Address Phone ii _��s Contractor ��'t'""" __Address Ak' License fro ' Phone�TZ� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACFMENT ❑ DESTRUCTION ❑ I� PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER foTa� '�S-(a 5atrk DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. ROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I` ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing [r[r ❑ Domestic/Private Cl Gra6el Pack ❑ Tracy Type of Casing Specifications .fir ! FI Public <1 Other Cl Delta Depth of Grout Seal Type of Grout IIII I I Irrigation Approx. Depth I I Eastern w 'h Repair Work Done ❑ Type of Pump H.P. t ' Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 �Mn W TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION I 1 DESTRUCTION I I (No septic system permitted lif public sewer is r� available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms I Character of soil to a depth of 3 feet: Water table depth ! SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments �! PKG. TREATMENT PLT. ❑ Method of Disposal Ip Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well foundation Property Line SEEPAGE PITS I 1 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation 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, I 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 s f q red inspections. Complete drawing on,r ver std Signed X Title: t+/� Date: Z ,� F DEPARTMENT USE O Y Application Accepted by Date Area 67 - I Pit or Grout Inspection by Date Final Inspection by Data Additional Comments: OO ❑ Stk 466-6781 El Lodi 369-3621 ❑ Manteca 823-7104 El Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I rE! I iNFK OUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. +.EH 1324 I Rr:V.1/n 57 'EH 14-26 F I f