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APPLICATION FOR.PERMIT ISAN 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. t , Job Address.1, S• .�� E��n h� �� p City Lot Size /71, a PM Owner's Name� Bll€ 5�,� a' Address 21�� '��fthtzku-, TPhone 2a�- O Contractor's Name License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i i ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public _ E Other: ❑-.Delta '^`¢ Depth-of Grout Seal - Type-df Grodt c• ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. I State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501) Depth Filler Material (Below 561) �} 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 !�,,,Eommercial,*,- y��th,� { Number of living units:A_ Number of bedrooms �a v Character of soil to a depth of 3 feet: s' "" Water table depth SEPTIC TANK 4� Type/Mfg 1 ) Capacity No.'Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: ++Well- Foundation Property Line LEACHING LINE I No. & Length of lines fgrA7 Lplig -Total length/size FILTER BED ❑ Distance to nearest: Well p Foundation Property Line � _.., q SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest:.« Well ' Y 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 0 + 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."Contractors 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 Callforn' .' The applicant fo I r inspections. Complete drawing on reverse side. Signed Title: Date: FOR DEP TMiENT,USE ONLY Application Accepted by Date I Area Pit or Grout Inspection by Date FinalInspectionby Date% 3 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 racy 835-6385 Applicant- Return all copies to: Envlronmental Health Permit/Services 1601 . Hazelton Ave., P.O. Box 2009, Stk., CA 95201 4 - k FEE' AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"N0. I INFO -7 Qy + EH 1324(REV.10183) ®.r'S� � ? v D(3 I EH 1428 _ - - +.