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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT _ 1601 E. HAZE T ON AVE., STOCKTON, CAj Telephone 12091 466-6781 PERMIT EXPIRES TYEAR 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.,} Job Address 6/0 City Lot Size PM r w Owner's Name. Address _ Pho /n Contractor Address ,1534 License No. �7 � � Phone �C1 TYPE OF WELL/PUMP: .NEW WELL ❑ WELL REPLACEMENT ❑ PUMP INSTALLATION ❑ SYSTE ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER DISPOSAL FLD. PRR OP. LINE FOUNDATION (CULTURE WEl L""�"" OTtiER'1+VELL= PITS/SUMPS INTENDED USE TYPE OF WELLROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open ' ` m ❑ Manteca Dia. of Well Excavation pia. of Well Casing ❑ Domestic/Private vel Pack ` 0:'Tracy Type of Casing Specifications f l Public ❑ Other ❑,Delta Depth of Grout Seal Type of Grout - I I Ifrigalion —.-Approx. Depth I I Eastern Surface Seal Installed by Repair W Done (03 Type of Pump H.P. State Work Done _ We estruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Materiai {Below 501 TYPE OF SEPTIC WORK: NEW INSTALI'ATION 1.1 REPAIR/ADDITION l I DESTRUCTION I 1 (No septic system permitted if public sewer is ` - -^-- �-- - - �-- Y-�---- available within 200.feet.) Installation will serve: Residence— Commerciale= Other i Number of living units: :Number of bedrooms , I Character of soil to a depth of 3 feet: ''• �; 1 IWater tahle.pth SEPTIC TANK ❑ Type/Mfg �' g Capacity No. Compartments r PKGr.,TREATMENT PLT. ❑ r -�` Method of Disposal Distance to nearest: Wel! Foundation Property Line # LEACHING LINE ` ❑ No. & Length of lines Total length/size lF r p y f 111 FILTER SL3ED � Distance to nearest: Well Foundation Pro en Line SEEPAGE PITS', I') Depth 4" "t Size Number SUMPS ❑ Distance to nearest'. Well Foundation Property Line l DISPOSAL_ PONDS ❑ t 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-. -• -- --�•- , l 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 shalt 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 California." ! ; The applicant m call for all required inspections Complete drawing on rev e side_. * p Signed X .. V Title: i�lr�L Date: (7FOR EPAR�ENT USE ONLY t �'" Application Accepted by �/► cn�vHi�� Date s ~l S -7 Areas Pit or Grout Inspectiony data Final Inspect' by - /Dated ,r Additional Comments: ✓/Z ,( -fr 6-.)/`f ❑ Stk 466.6781 ❑ Lodi -3621 ❑ Manteca 823-71M ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE r INFO AMOUNT DUE AMOUNT REMITTED CASH REC/E�IV�ED BY DATE PERMIT'NO. +.EH 14-24(REV.t/x 51 03�.ov f L1JC (� II tL7 EH 14-26