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1 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 DATCISSUED 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 welltpump and the Rules and Regulations of the San Joaquin Local Health District. Job Address _T(' a k - City �� Lot Size PM Owner's Name _ '�%L' �L� ss �� Phone Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O F DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. 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 ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout '❑ Irrigation _...---Approx. Depth o.❑.Eastern Suriace'Seal Instal ed,by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WOJRK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION MANo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial Other Number of living units: Number of bedrooms1,' I Character of soil to a depth of 3 feet:, Water table depth I SEPTIC TANK ❑ Type/Mfg, Capacity No. Compartments 3 PKG. TREATMENT PLT.`!j Method of Disposal IDistance to nearest: Well Foundation Property Line L I LEACHING LINE ❑ No.�& Length oflilines Total length/size 7t� r t , FILTER BED ❑ Distance to nearest: Well Foundation Property tine SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well yy Foundation - Property Line 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. 11 Home owner or licensed agent's signature certifies the following: 'T,certlfy 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:'9 certify that in the performance of the work for which this.permit is,issued,I shall employ persons subject to workman's compensa- ;a..Mtion laws of California.'; „w � The applicant mu --call for all required inspections. Complete drawing on reverse side. Signed X ��'�� / Title: Date: F R DEPARTMENT USE ONLY Application Accepted Date /10-02,7-me. /Area Pit or Grout Inspection y Date Final Inspection by F Data/U � Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6395 Applicant- Return all copse ental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 s. FEE AMOUNT DUE AMOUNT REMITTED K' RECEIVED BY DATE PERMIT`NO. INFO ,pr + EH 13-24IREV.1/051 tj1�Q 3 S, a 3 - 1,0/j-'7 C6 ,. EH 1428 H