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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1�» 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (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 District. G Job Address1� +� �, - City SC �'�Lot Size X / PM Owner's Name ."M =au b u C O Address &1�04Ar X `73i _�JL1C r .b,A A0 Phone Contractor©/4k!;h01r_ Crow d. Address � �� r"= S��—License No. �C7IS Phone TYPE OF WELL/PUMP: NEW WELL D. WELL REPLACEMENT.Lq DESTRUCTION._❑° -4 —_PUMP INSTA LATIO _ DISTANCE TO NEAREST: SEPfiIC—TAN SEWER Lfv�p� DISPOSAL FLD. PROP. LINE FOUNDATION`��F AGRICULTURE WELL ! OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WI LL PRfkQ EM AREA CONSTRUCTION SPECIFICATIONS i E ❑ Industrial if ❑ Open Botta ❑ Mame,6 Dia. of Well Excavation f Dia. of Well Casin ❑ Domestic/Private ❑ Gravel Pack i ❑ Tracy Dia. of Casing -- Specifications M Public 1 l� Other ❑;Delta Depthaf rout Seat i Type of Grout I Ifrigation --Approx. epth' I Il,Eastern" Surface Seal installed by, Repair Work Done t C Type of Pump H.P. `State Work Done_ Well Destruction 10 Well Diameter Sealing Material atop 501 1 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTA LATION I 1 REPAIR/ADDITION DESTRUCTION XiNo septic system permitted if pu is sewer is-- _ available within 200 fee£.1 Installation will serve: Residence Commercial:- Other Number'6f diving units: Number of.bedrooms Character of soil to a depth of 3 feet: .r ur Xe,4,----- Water table depth SEPTIC TANK Type/Mfg Capacity 00 No. Compartments PKG. TREATMENT PLT. ❑ t Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Len h of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS € I Depth Size Number SUMPS L1 Distance t nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this pplication and that the work will be done in accordance with San Joaquin county ordinance state laws, and rules and regulations of the San Joaquin ocal Health District. Home owner or licensed agent's signature certifies the following: certify t at m the pe ormance o 111e wor or w tc i ued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractoes 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 mus call for all required i s eti ns. omplete drawing onreae�rse side. Signed Title: �T Date: FOR DEPARTMENT USE ONLY Application Accepted by MADate `��!_ Area Pit or Grout Inspection Date Final Inspection b �i Date �� Additional Comments: 0l rr m d i-- Tv b _...1?£ ~ � £-r.✓ q q✓ ❑ Stk 466-6781 ❑ Lod'r 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 ,t Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. BoxFEE Stk., CA 01 INFO NT DUE AMOUNT REMITTED CASH CK 4 RECEIVED BY DATE PERMIT-NO. TEH 13.24(PEV.1/9s) 1-70EH 14-2C- 1;z� - ;q