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F APPLICATION FOR PERMIT . SAN JOAQUIN LOCAL. HEALTH DISTRICT /�,�+ 1601 E. HAZE.T ON AVE., STOCKTON, CA r'" I Telephone (209) 466-6781 ,PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San JLocal 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. 1662 for well/ and the Rules and Regulations of the San Joaquin oaquin Local Health District. 3 3 Se City Lot Size PM Job Address '� lsvLC+�/!` ,+�J �3 3 �r ©�O Phone L .-15-- Owner Owner's Name _ Address ST r ,I, 'I t License No-30 �,1 Phon277 Contract " "'� ddress TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT F-1 DESTRUCTION ❑ 'w. ' PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ + DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTIDN SPECIFICATIONS Dia. of Well Casing ❑ industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Type of Casing Specifications m ❑ Domestic/Private i❑ Gravel Pack ❑ Tracy Type of Grout W I'1 Public ❑ Other ❑ Delta Depth of Grout Seal yp 011 I I Irrigation Approx.1 Depth I I Eastern Surface Seal Installed by - �1 ■ H P State Work Done Repair Work Done ❑ Type of Pump Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth I Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I'l REPAIR/ADDITION I I DESTRUCTION availabo septic system pein fe fitted i( public sewer is -� Installation will serve: Residence J -Commercial_ Other I v Number of living units: Number of bedrooms O Character of soil to a depth of 3 feels Water table depth " SEPTIC TANK ❑ Type/ g Capacity No. Compartments Method of Disposal PKG. TREATMENT PLT. ❑ Distance;to nearest: Well Foundation Property-Line A Total length/size LEACHING LINE ❑ No. & Length of lines i FILTER BED ❑ Distance,to nearest: Well Foundation Property Line l ,I SEEPAGE PITS l I Depth I'� Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line { DISPOSAL PONDS ❑ I + 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 Il rules and regulations of the San Joaquin Local Health D3trict. 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 I certifies the following: "I certify that in�the perfofmance of the work for which this permit is issued, I shall employ persons subject to workman's compensa tion laws of California." r Theapplicant must ca fo ctions. Complete drawing on reverse side.,, Signed X10 Title: Lyf s7 "`�`�' Date: 3 FOR DEPARTMENT USE ONLY a ' Date v Z J Area Application Accepted by Pit or Grout inspection by Date Final Inspection by Date- � Additional Comments: i ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385O. 35-Ave., P.., p. O. Box 2009, Stk., CA 95201 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton FEECK RECEIVED BY DATE PERMIT'NO. I INFO AMOUNT DUE AMOUNT REMITTED CASH +.EH 13-24 IREV.I/K 51 -- 1 EH 14-26