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F APPLICATION FOR,PERMIT SAN'JOAQUINLOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone .12091 466-6781 Y fir.. .."st9 PERMIT EXPIRES 1'.Y.EAR FROM DATE ISSUED f/4. illi 378/1110 f),(Complete in Triplicate?.,, ; Application is hereby made:to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is made.in compliance wi#h 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. —,_ l �✓ �t9+`ix jtt: �} ir . , .-. • '• �!- f7.fl. ' iv�D Cy — Lot Size PM Job Address Owner's Name _ yam`' Address � �! " 5 _ Phone - ';, - •- �-••� '� "- Phone . Contractor's Name r License No. I TYPE OF WELL/PUMP: , NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 4 } "t` PUMP INSTALLATION 17 SYSTEM REPAIR 17 OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE; FOUNDATION I AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom r ❑ Manteca Dia. of Wall Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack {" 11Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout -❑ Irrigation i _-LApprox. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well.Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 r TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION`❑,(No septic-system permitted if public sewer is • available within 200 feet.) Installation will serve: Residence— Commercial_ Other {, Number of living units: Number lof bedrooms . Character of soil to a depth of 3 feet: t ..—Water table depth a ... SEPTIC TANK ❑ Type/Mfg f Capacity----� 'No. Compartments PKG. TREATMENT PLT. ❑ J Method of Disposal Distance to'nearest: Well Foundation Property Line 1 1 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED I ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS 'I❑"Di§tance to_nearest: Well. r "= Foundation Property Line DISPOSAL PONDS }❑ I hereby certify that I have prepared this application and that the work will be done in.accordarlce 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. F The applicant us(call for all req d)nspecti ns. Complete drawing on reverse side— Signed Title: �A - h/ '. Date: ��, rw FOR DEPA TMENT USE ONLY _ Application Accepted by. �!`' "" Date "'"a � ,; �._,._.: »M Date �'�43 r :Pit dr Grout Inspection by Date — Final lnspeciion by AdSlIltional Comments: ^' Stk 466 6781 13 Lodi, 369 3621 t `=' O Manteca' 823 7104 ❑-Tracy"835-6385 pp e t- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 A i * -'r FEE AMOUNT DUE i " AMOUNT REMITTED cK RECEIVED BY DATE : PERMIT`NO. ' INFO + EH 13-24{REV.10/EnF r EH 14-28 i LD:d _ - _