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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE.T ON AVE., STOCKTON, CA Telephone (209 LA466-6781 PERMIT EXPIRES 1'YVJ RSM DATE ISSUED 1 {Comp) e n Tri�icate)_ 1 Application is heieby nce made to the San Joaquin Local Health District for aappermit 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 RWu lotions of the San Joaquin f Local Health District. °. I 1. �� City Lot Size �� r PM 1 Job Address l f fz Owner's Name Address �" ' Phone Contractor - Address License No ' --Phone-7>&9--122' TYPE,OF WELL/PUMP: ry . NEW WELL �+ WELL-REPLACEMENT-❑ DESTRUCTION 11 - T PUMP INSTALLATIONL)K— SYSTEM REPAIR ❑ OTHER ❑ bISTANCE TO NEAREST: SEPTIC TANK eQ SEWER LINES DISPOSAL FLD.L� PROP. U FOUNDATION f 1 AGRICULTURE WELL OTHER WELL PITS/SUMPS IVIPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial 9-Open Bottom ❑ Manteca Dia. of WeH Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack 17Tracy Type of Casings Specificaiians f Public ❑ Other 171 Delta Depth of Grout Seal Typ of Czrout '�^�� — I I Irrigation --Approx. Depth I Eastern Surface Seal Installed by U0 zf'nl - Repair Work Done ❑ Type of Pump ' H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50'1 A. 4 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION is FlEPAIR/AODiTION I 1 DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) _ .installation will serve: Residence_ Commercial Other Q Number of living units: Number of bedrooms '- rWater table depth Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG.iTREATMENT PLT. ❑ Method,of Disposal } Distance to nearest: Well Foundation Property Line a LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED - + ❑ Distance to nearest: Well Foundation Property Line E SEEPAGE PITS I I . Depth Size Number ) SUMPS L-I '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 Di§trict. ` 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 applicant must call for all re uirad inspections. Complete drawing on reverse si e. r� Signed Title: :~ — ` Date: l� 4 FOR DEPARTMENT USE ONLY r � Application Accepted by t _ Date v Area IE Pit or.Grout Inspection by Date Ab2Final Inspection by Date �•' �CGC� Additional Comments: ❑ Stk -466-6781 Lodi . 369-3 21 ❑ Manteca 823-7104 —Cf Tracy 835.6385 •• Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. ox 2009, Stk.., CCA 95201 t.� FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO, INFO CASH _ a + EH13-24MEV.iinsl lOs`� EH 14-26