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x I APPLICATION FOR PERMIT i SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone {209} 466-6781 PERMIT EXPIRES 1 YEAR 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. IA j. _ /5 5�j� 7d _ PM i Job Address ,r fr C/ity Lo�t�Size (� �j Owner's Name i�e 7 �rAddress � ! �� *, Phone � �T / { Conlractor ` ��_1 1yt di-Address C ��t7`��i�lK//t License [Vo. 7�Phone k TYPE OF.WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE i z FOUNDATION AGRICULTURE WELL OTHER WELL PIT$/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �{ LIIndustrial ❑ Open Bottom ❑ Mant,3Ca ~,� Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'I Public ❑ Other F i ❑ Delta , Depth of Grout Seal Type of Grout _ t I 1 Irrigation ---Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ r Well Destruction ❑ Well Diameter -Sealing Material (top 5011. Depth ! Filler'Material (Below 501 f TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR74DITION I I DESTRUCTION 111No septic system permitted it public sewer is. ' i available within 200 feet.) I Installation will serve: Residence Commercial Other - f Number of living units: Number of bedroom Character of soil to a depth of 3 feet: E 4 � F +Water table depth � SEPTIC TANK Type/Mfg �i�- Capacity No. Compartments �— PK G. TREATMENT PLT. ❑ f. !Method of Disposal Distance to nearest: Well d. T Foundation A9 ! Property Line ��J t i LEACHING LINE No. & Length of lines Total length/size CPQ 2 FILTER BED ❑ Distance to nearest: Well..� � -Foundation' - -Property Line j .F- SEEPAGE PITS Depth ) Size Number SUMPS ❑ Distance to nearest: Well Foundation %_-Pioperty 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 t rules and regulations of the San Joaquin Local Health DRtrict. - S Home owner or`icensed agent's signature certifies the following; "I certify that in the performance ofthe 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-. 1 tion laws of California " The applic f alspectio omplete drawing on r vers side. t �s Signed X 2 Title: ALol-107 Date: FOR DEPARTMENT USE ONLYP Application Accepted by J Date r Area r /— i . 7r Pi or Grout Ins ' Pection b Y Dat �� Final Inspection'by Dat Additional Comments: ` J ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca /323-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave.,"P.O. Bax 2009; Stk., CA 95201 FEE INFO AMOUNT/DUE AMOUNT REMITTED CAS RECEIVED BY DATE IRX�?Jt PERM17EH 13-24 EH 14 IREV.t i w 57 �� V6 LY v 2 6 -T I �/7