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APPLICATION FOR PERMIT PAYIIAENT RECEIVED SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA ,JAN 12 Telephone (209) 466-6-781 a PERMIT EXPIRES 1 YEAR FROM DATE ISSUED .y J (Complete in Triplicate) r install the work herein L This Application-is herab made to the San Joa uinnCounty Ordinauin lncle Nth District for a o.549 for sewagcation is e or permit No. 1862 for construct ell/dpump and the Rules and Regulations of he San�Joaquin made in compliance Local Health District. 15W 1 � City``�[��Lot Size PM Job Address i1nra dP �.. 9 c/JlC Address /7 ry�o/7 Phone i Owner's Name. �ci 3� •i!c C/vrc� `lar-�d J �'rc.'SvcTA�llT Gc)�SS , saC��9°r5 Contractor "D2t t-z.J Addressr Y � � t(AstI�7L'�.i�ense No.(2�,$aq�5 Phone NEW WEL SYSTEM REPAIR REPLACEMENT ❑ DESTRUCTION W. © � TYPE OF fLL/PUMP: . OTHERX I PUMP INSTAtLATION ❑ � f DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES X35! ISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL l PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �J 1 ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Industrial �rf1 1 Type of Casing Specifications ❑ Domestic)Private `❑ Gravel Pa ❑ Tracy yp g �� Type of Grout Public yu Other ❑ Delta Depth of Grout Seal 11 Irrigation Approx. Depth i I Eastern Surface Seal Installed by Type of Pum HP /J Sta a Work Done Repair Work Done ❑ p H.P. ' Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth I Fillet Material IBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIRlADDITION l I DE=STRUCTION l I (No septicailable system in rented if public sewer is Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEP,TlC TANK ❑ Type/Mfg Capacity No. Compartments � ..<rpplf.-, r Method of Disposal h PKd. TREATMENT PLT. ❑ r Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line ' DISPOSAL PONDS ❑ 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 he performanceofCalif 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 Paws 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." Theapplicant must call for all required inspections. Complete drawing on reverse side. Signed X Title: 7 a' I FOR DEPARTMENT USE ONLY Date Area Application Accepted by � �� ,� Pit or Grout Inspection by Date 5 Q U Final Inspection by Date Additional Comments: ❑ Stk 466-6781 L] Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 F1 E AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INfO _y�7�AMOUNT DUE �j� + EH 13-24 iREV.ti i H 51 �"V 3�a . vlJ �b"lJ �• 5' l V CD r EH 1426