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APPLICATION FOR -PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE„ STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED "- 9 (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. 1852 for well/pump and the Rules and Regulations of the. San Joaquin Local Health District. «e Job Address 'l "I-,/4�Lot Size `T M 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 performince-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 all requir d i is ctions. Co tete awing onr e side. Signedx.= _Title: 71,-? I FOR DEPARTMENT USE ONLY Application Accepted by Date Pit or Grout Inspection by rt' Date r Final Inspection by Additional Comments: I ❑ Stk 466-6761 ❑ Lodi .369-3621 ❑ Minteca 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 i + EH 13-24 MEV. 101631 EH W26 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH Owner's Name Address Phone ^ Contractor's Nameicense No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ x - i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE I 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 ❑ Domes tic/Privatef ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public, I ❑ Other ❑ Delta Depth of Grout Seal Type of Grout—.z....' ❑ Irrigatiori --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H. P. State Work Done Well Destruction 1 ❑ Well Diameter Sealing Material (top 501 / Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEIN INSTALLATION REPAIR/ADDITION E]DESTRUCTION 71(No septic system permitted if public sewer is r available within 200 feet.) Installation will serve: Residence- Commercial _ Other Number of living units: _/_ Number of bedrooms Character of soil to a depth of 3 feet: A-A—P-7 Water table depth SEPTIC TANK ❑ Type/Mfg Capacity. Q1�.. 1 No. Compartments 742, PKG. TREATMENT PLT. ❑ ® - �' Method of Disposal Distance tonearest: ' Well ation '`�e Property Line !L_ 2v y LEACHING LINE No. &Length of lines, - 0 .Total length/size FILTER BED ❑ Distance to nearest' Well Foundation Property Line SEEPAGE PITS Depth ^ ~ Size _ Number SUMPS ❑ Distance to nearest: W611'_Foundation 'Property tine DISPOSAL PONDS ❑ 1 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 performince-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 all requir d i is ctions. Co tete awing onr e side. Signedx.= _Title: 71,-? I FOR DEPARTMENT USE ONLY Application Accepted by Date Pit or Grout Inspection by rt' Date r Final Inspection by Additional Comments: I ❑ Stk 466-6761 ❑ Lodi .369-3621 ❑ Minteca 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 i + EH 13-24 MEV. 101631 EH W26 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. ( —t 1—