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�• a APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALT9_DISTR CT ` 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209),466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED A (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 Ordinan a No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. 1/�� Job Address _. C� (, (((WA�i City ~_/R< Lot Size PM 1 Owner's Name 1104 Address „ Phone Contractor 1 AddressLicense No, i��vTca -Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 1-1DESTRUCTION ❑ r.; s " PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ }� { A 44 DISTANCEf70 ., SEPTIC TANK SEWER LINES DISPOSAL FLO. t E �" FOUN AGRICULTURE WELL OR PIT5/SUMPS 3 ' INTENDED USE TYPE OF WELL PROBLE CTION SPECIFICATIONS , El Industrial ❑ Open Bottom �I] Aaffteca Dia. o vation Dia.Dia., Casing ❑ Domestic/Private 1-1eLPaok� El Tracy y N_ Type of Casing W _�. . Specfications" Ll Public 1�'"❑""OtfieT`"- - ❑ Delta Depf i of Grout`5ea1— Grout ❑ Irrigation_ --Approx. Depth ❑ Eastern Surface Seal Installed by 'y air Work Dane ❑ Type of Pump H.P. f . +State Work Done Well Destruction ❑ -Well Diameter Sealing Matehal;(t6pr801 ' Depth Filler Material (Below 50 F f TYPE OF SEPTIC WORK:," NEW INSTALLATION ❑ REPAIR/ADDITIOISTX DESTRUCTOM❑ (No septic system permitted if public sewer is .available within 200 feet.} j Installation will serve: -Residence�e commercial— Other J Number of living units. Nu„tuber of.6edrooms 1 Character of soil to a depth of 3 feet: ”' Water table dapth SEPTIC TANK ID Type/Mfg - 10_o4_)- pli- ! �Capacity1 '2 No- Compartments _ _a PKG. TREATMENT PLT. t'; Method of,Disposal + �, Distance to nearest: Well Foundation , Property Ling - `LEACHING LINE No. & Length of lines btal lengfh/size FILTER BED O ,Distance to nearest: r Well Foundation D/� Property'line SEEPAGE PITS CO Depth „�� I SUMPS � Distance'to nearest: Well ------ Property Line- DISPOSAL PONDS ❑ I hereby certify that'l have prepared this application and thaf;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 applicant must call for all equiiad inspections. Complete drawing on reverse side. r Signed X .S i Title: ( -t/Z� Date: 5 ZFEPARTMENT USE ONLY !�7 �]Application Accepted by Z � Date � / / p ' Area ' Pit or Grout Inspection by; D e. --- "--- ---=- Final.Inspection-by " Date Additional Comments: - ❑ Stk 466-6781 ❑,Lodi "369-3621 ❑ Manteca -823-7104 ❑ Tracy 63540% Applicant- Return all,copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 t FEE AMOUNT-,D.UE _ _AMOUNT.REMITTED _,.__CK ... RECEIVED-BY f "_ DATE' PEAMIT''NO "„' .., INFO... - CA H" , EH 13-24(REV.v/95) i