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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT t 1601 E. HAZELTON 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 ereirrcli d. This} t made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Aulespiegulats of the 5 [ Local Health District. �, U vv r.a Job AddresA?�:,--)-- I ei City Lot Size ��F T�! PM cq , FS �lti Owner's Name 3./Address S� ` Phone cc,�� -6 i Contracto .� Address&&& Joe-, ��Llcense No. W-'-— Pho,eM41 :fid l TYPE OF WELUPUMP: NEW WELL ❑. WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK . SEWER LINES DISPOSAL FLD. PROP. LINE 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 L,Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 11 Public F-1Other "4 F1 Delta Depth of Grout Seal Type of Grout I I irrigation _ _Approx. Depth I 1 Eastern *-� Surface Seal Installed by _ Repair Work Done Type of Pump H.P. `^Ltr State Work Done Well Destruction ❑ Well Diameter Seating Material (top 501 - Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I:1 REPAIR/ADDITION l J DESTRUCTION i I (No septic system permitted if public sewer is ,) available within 200 feet.) N Installation will serve: Residence_: Commercial_ Other', F Number of living units: Number of bedrooms r• "' A .Character of soil to a depth of 3 feet: 4ti Water table depth w" SEPTIC TANK s ❑ Type/Mfg Capacity _ No. Compartments PKG. TREATMENT PLT. ❑ 9 Method of Disposal , Distance to nearest: Well Foundation r Property.Line OdQ LEACHING LINE ❑ No. & Length of lines " Total length/size FILTER BED ❑ Distance to' 4 'nearest: Well i Foundation "" Property Line I f , SEEPAGE PITS I I Depth I Size Number SUMPS ❑ Distance to nearest: Well Foundation Property 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 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." The apphcan tali r II requod inActions. Complete drawing on rse side. ff..,, Sign Title: Date: Ila— Ga o a 11 I FOR DEPARTMENT USE ONLY 1 Application Accepted by r Date C` 1 11 Area Pit or Grout Inspection by a Final Inspection by Date 'f Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 . 0 Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE '.t AMOUNT REMITTED— CKO CASH RECEIVED BY DATE PERMIT'NO. +.EH13!4.29(REV EH .r/x 51 "26 '-�•�j0