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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE„ STOCKTON, CA Telephone {2091 466-6781 PERMIT EXPIRES T YEAR FROM DATE ISSUED 4 (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 I Local Health District. I' / € Job Address 3 a It 4 f �G City Lot Size ,-_ PM Owner's Name42.11 Address Phone Contractor T5f i�i �!/ �� Address 13r l JL��1License N Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION j. 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 T ' 4 ❑ Domestic/Private ❑ Gravel Pack 4 F1 Tracy Type of Casing Specifications ['] Public ❑ Other I I l Delta Depth of Grout Seal Type of Grout - i I Irrigation ---Approx.'Depth l I Eastern Surface Seal Installed by Repair Work Done .❑ Type of Pump H.P. State Work Done _ 4 Well Destruction ❑ Well Diameter Sealing Material Stop 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION- :REPAIR/ADDITION I I DESTRUCTION I I lNo septic system permitted if public sewer is `r"`"�"�-'" avallaSle wiiFiiri 20D-fi3ef.)`' �! Installation will serve: Residence Commercial Other Number Number of living units: _/__ Number of bedrooms ._._ Character of soil to a depth of 3 feet:I Water table depth SEPTIC TANK ..❑ -TYp67Mfg p 1. i" —Capacity ""'No. Compartments :PKG. TREATMENT PLT. ❑ ` •' t / T Method of Disposal Distance to nearest: Well- Foundation Property Lihe-.A57�it'7" I LEACHING LINE No. &-Length of lines Total length/size FILTER BED ❑-< Distance to nearest: Well Foundation '---property'Line Well - SEEPAGE PITS 11"Depth / �- .—Sizer Number` SUMPS Distance to nearest:` Well <~oundation{ Y 'E�"Property Lime DISPOSAL PONDS t O w, _ ~i 'I hereby certify thdi I have.prepared this applicatiornafid that the work will be'done in accordance with San Joaquin county ordinances, state laws, and j rules and regulations of the San Joaquin Local Health District. - p Home owner or licensed agent's signature certifie the following: "I certify that in the p6Hormance of the work for which this permit is issued, I shall not fT 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-must call forR I required inspections. Complete drawing on reverse side. Signed X � _ Title: �-�l�P�C� Date:: • � L /PFR I?EPARIMENT USE ONLY . "r r Application Accepted by 4 Date- / 4 Area Pit or Grout Inspection by s Date — Final inspection by ge 1 U/� Additional Comments: .,❑...Stk. 466-6781 ❑ Lodi 369:3621-k.._.,._.❑ MantecaA 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 ' INFO— ..,,AMOUNT OUE " ""AMOUNT REMITTED— —CK CASH --sa RECEIVED BYE DATE PERMIT'NO. + EH 13.24(REV•t i K 51 EH 14-26 0 f ..