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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA (� Telephone (209) 466-6781 �! PERMIT EXPIRES 1 YEAR FROM DATE ISSUED u (Complete in Triplicate) yy^^ �9$g Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work hereirAUcribed. 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 Regulatigr ��th"§WAaquin Local Health District. �N\fli�ONVIj' PERM RV10ES ! Job Address �` City Lot Size PM Owner's Na 1 ZZW1 address Phone 10 v Contractorgwli�ddress T 7 8 e&No.J PhoneJ3 `Z TYPE OF WELL/PU NEW ELL ❑ WELL REPLACEMENT ❑ QESTRUCTION PUMP INSTALLA ON ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. 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 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ("I Public C1 Other Cl Delta Depth of Grout Seal f Grout I I irrigation --Approx. Depth i I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Workon L r Well Destruction ' Well Diameter Sealing Material (top 50'1 Depth S7 Filler Material (Below 50') 9 a -S` TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION I i INo sept system enfitted it lic sewer is available ' in fee . 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 SEPTIC TANK 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 0 Method of Disposal Distance to nearest: Well Foundation Property.Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED 0 Distance to nearest: Well Foundation Property Line TJ SEEPAGE PITS I I Depth Size _ Number CF SUMPS 0 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 applicantst -red inspe plate drawing on reverse side._721 Signed X Title: Date: FOR DEPARTMENT USE ONLY '1 Application Accepted byv e Date — Area AnO Pit or Grout Inspection by Data Finj Inspection by � ' Date-A 141` Additional Comments: P it/ l.G► Q ❑ Stk 456-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 0 Tracy 835-6385 V Applicant - Return all copies to: Environmental Health Petmit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ? "Vf INFO FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT IVO. 1 EH 3.24 EV.I/A51 }/gyp/ T� EH 144-28 �� .-