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APPLICATION FOR PERMIT - SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED j (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 Heal&".District. PM 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 Sari Joagwn Local Health District. ; Home owner or licensed agent's signature certifies the following: "l 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." 9 y - - t The applicant must call for all: required inspecti s:-Compiete-drawing,on-reverse-side. 4 Signed Title: Data: _2Zi�, II FIDR DEPARTMENT USE ONLY k — --F Date %, �eArea Application Accepted by - - Q Pit or Grout Inspection by fy"Date Final Inspection by Z1V^' Date 1 ! +� i�Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 1 Applicant- Return all copies -to: -Environmental -Health -Permit/Services; -1601 -E-Hazelton --Ave.-P70-Box 2009, Stk., CA 95201 + EH 1324 (REV. 10/831 EH 1426 FEE INFO1-I' AMOUNT DUE Owner's Name ` of Phone 21 F-- 7 D Adilress4F Contractor's Name ��f License No.:,,.2 7 �� Phone TYPE OF WELL/PUMP: NF.W;W.ELL;.❑,,.,,.,'WELL-REP.LACEMENT ❑—DESTRUCTION ,❑ yy S� PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 Da. of Well Casing ❑ Domestic/ Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ___�4pprox. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type'of Pump kL H. P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 w z- r Depth Filler Material (Below 501 t TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence fCommercial — Other Number of living units: '" II Number of bedrooms -3 ! %.Character'of soil to a depth of 3 feet: - fez" Y Water table depth TANK i .200 9� No. .SEPTIC '�. Type/Mfg /dR /1�'!.S/i _ _Capacity^ Compartments � .PKG. TREATMENT PLT. ❑ r --rt Method of Disposal Distance to nearest: Well A Foundation Property Line X IE LEACHING LINE ❑ No. & Length' df lines " y" Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth. ' Size Number SUMPS `� ❑ Distance to nearest: Well Foundation Property Line DISPOSAL -PONDS 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 Sari Joagwn Local Health District. ; Home owner or licensed agent's signature certifies the following: "l 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." 9 y - - t The applicant must call for all: required inspecti s:-Compiete-drawing,on-reverse-side. 4 Signed Title: Data: _2Zi�, II FIDR DEPARTMENT USE ONLY k — --F Date %, �eArea Application Accepted by - - Q Pit or Grout Inspection by fy"Date Final Inspection by Z1V^' Date 1 ! +� i�Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 1 Applicant- Return all copies -to: -Environmental -Health -Permit/Services; -1601 -E-Hazelton --Ave.-P70-Box 2009, Stk., CA 95201 + EH 1324 (REV. 10/831 EH 1426 FEE INFO1-I' AMOUNT DUE AMOUNT REMITTED CK # CASH RECEIVED BY DATE PERMIT N0. ' yy S� ;L-, --V jj II C ��Vr1&S